PIGMENTARY  SYPHILinE  AND  ALDPE CIA  (Author's  case 

fram    King's    CDunty  Hospital),      PatlBnt  was   a  famalB,    aged 

seven  years,  with  acquired  Syphilis,  and  presented  a  diffusa, 

"wrtde-spread    dark    pigmentation    over  body   and    neck, 

with    areas    of    white    healthy    skin    scattered    here 

and    there    through    It,     The    Alopecia    occurred 


Genitourinary  Diseases 
AND  Syphilis 


BY 


HENRY  H.  MORTON,  M.D. 

Cli.mcal  Pkofessor  of  GBNiTOURiNARr  DfSEiSES  in  the  Long  Island  Collegk  IIosimtal;  GExiTo-nRiNART 
Surgeon  to  the  Long  Isi-aaVd  College  and  Ktngs  Cocntv  HosrixALS  and 

THE   FOLHEMUS   MEMORIAL   CLINIC. 


Illustrated  \»\th  ])alf'tone$  ana  f ulPpage  eolor  plates 


Philadelphia 

F.  A.   DAVIS  COMPANY,  PUBLISHERS 
1903 


Entered  According  to  Act  of  Congress,  in  the  Year  1902, 

Bv  HENRY  n.  MORTON. 

in  the  Office  of  the  Librarian  of  Congress  at  Washington,  D.  C. 

All  Rights  Reserved. 


Philadelphia.  Ph.,  U.  S.  A.: 

The  Medical  Bulletin  Printing-house, 

19U-1G  Clierry  Street. 


6io. 

WJ 

100 


TO  THE  MEMORY 

OF 

MY  OLD  TEACHER  AND  FRIEND 

Dr.  Alexander  J.  C.  Skene 

IN  RECOGNITION  OF  HIS  BRILLIANT  ABILITIES  AS  A  SURGEON 

AND  IN  AFFECTIONATE  REMEMBRANCE  OF  HIS 

PERSONAL  QUALITIES  AS  A  MAN 

THIS   WORK   IS    DEDICATED 


PREFACE. 


In  the  past  ten  j^ears  no  branch  of  surgery  or  medicine  has  made 
greater  progress  than  the  department  of  genito-iirinary  surgery.  In 
that  short  period  of  time,  the  treatment  of  acute  and  chronic  gonor- 
rhoea has  been  removed  from  mere  empiricism  and  placed  upon  a 
scientific  and  rational  basis.  This  has  been  accomplished  through 
investigations,  whose  results  have  given  us  a  definite  knowledge  of 
the  micro-organisms  concerned,  and  the  pathological  changes  in  the 
urethral  tissues  which  their  presence  excites. 

The  whole  subject  of  chronic  seminal  vesiculitis,  with  its  relation 
to  sexual  neurasthenia,  and  the  ever-present  danger  of  lurking  infec- 
tion, has  been  clearly  demonstrated.  It  is  less  than  ten  years  since  the 
cystoscope  came  to  be  of  practical  use,  and  out  of  its  development 
grew  the  various  instruments  for  collecting  the  urine  from  each  kidney 
separately,  in  this  way  stimulating  a  greater  interest  in  the  subject  of 
renal  surgery. 

While  the  operations  for  stone  in  the  bladder  are  as  old  as  civiliza- 
tion itself,  the  improvements  in  the  technique  of  lithotomy,  and  a 
clearer  comprehension  of  the  indications  for  each  form  of  operation, 
are  matters  of  very  recent  growth.  Ten  years  ago  the  cases  of  hyper- 
trophied  prostate  in  old  men  were  without  remedy,  after  the  failure 
of  the  catheter  to  alleviate  the  urgent  symptoms,  but  to-day  the  opera- 
tions of  prostatectomy,  castration,  and  Bottini's  operation  have  opened 
a  way  of  relieving  the  suffering  and  prolonging  life. 

The  above-mentioned  advances  are  only  a  few  of  the  steps  in  the 
progress  of  this  important  branch  of  surgery. 

(V) 


yi  PREFACE, 

In  this  little  volume  the  author  has  endeavored  to  present,  in  a 
concise  form,  the  present  status  of  genito-urinary  diseases  and  syph- 
/^is^-.  At  the  same  time  he  has  endeavored  to  keep  in  mind  the  needs 
^--Sf^he  practitioner,  whose  opportunities  for  seeing  such  cases  may  be 
infrequent,  and  to  consider  the  questions  of  diagnosis,  prognosis,  and 
treatment  in  such  a  way  that  the  book  may  be  of  practical  use  in  these 
matters. 

40  SCIIERMERnORN   STREET, 

Brook LYN-^'EW  York. 


CONTENTS. 


DISEASES  OF  THE  PENIS.  „.„„ 

Chapter  I. — Phimosis.     Balano-posthitis.     Herpes  Progenitalis.     Papillo- 

mata.     Cancer  of  the  Penis 1 


DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

Chapter  II. — Anatomy  of  the  Urethra 16 

Chapter  III. — ^Acute  Urethritis 22 

Chapter  IV. — Posterior  Urethritis  41 

Chapter  V. — Chronic  Urethritis   46 

COMPLICATIONS  OF  ACUTE  GONOERHCEA. 
Chapter  VI. — Balanitis.     Phimosis.'     Paraphimo.sis.     Folliculitis.      Cow- 
peritis.     Inguinal  Adenitis.     Chordee.     Epididymitis. 
Gonorrhceal  Rheumatism  75 

INFLAMMATIONS  OF  THE  PROSTATE. 
Chapter  VII. — Acute  Prostatitis.     Chronic  Prostatitis 84 

DISEASES  OF  THE  SEMINAL  VESICLES. 
Chapter  VIII. — Acute  Seminal  Vesiculitis.     Chronic  Seminal  Vesiculitis. 

Tuberculous  Vesiculitis 91 

STRICTURE  OF  THE  URETHRA. 

Chapter  IX. — Spasmodic  Stricture.  Organic  Stricture.  Treatment  of 
Stricture  by  Surgical  Operation.  Extravasation  of 
Urine   102 

Chapter  X. — Urinary  Fever.    Care  of  Urethral  Instruments 130 

DISEASES  OF  THE  BLADDER. 

Chapter  XL — Cystitis.     Bacteriuria.     Tumors  of  the  Bladder 134 

Chapter  XII. — Vesical  Calculus   159 

(Vii) 


viii  CONTENTS. 

DISEASES  OF  THE  PROSTATE.  p^^j. 

Chapter  XIII. — Senile  Hypertrophy  of  the  Prostate 181 

Chapter  XIV. — Operative  Treatment  of  Hypertrophied  Prostate 202 

Chapter  XV. — Tuberculodis  of  the  Prostate 221 


DISEASES  OF  THE  KIDNEYS. 
Chapter  XVI. — Movable    Kidney.      Renal    Calculus.      Pyelitis.      Hydro- 
nephrosis       226 

DISEASES  OF  THE  TESTICLES. 
Chapter  XVII. — Ectopy  of  the  Testicle.     Malignant  Disease.     Tubercu- 
losis.    Syphilis    243 

HYDROCELE,  HEMATOCELE,  AND  VARICOCELE. 
Chapter  XVIII. — Hydrocele.     Hsematocele.     Varicocele 255 

CHANCROID  AND  ITS  COMPLICATIONS. 
Chapter  XIX. — Chancroid.     Complications   271 

SYPHILIS  AND  ITS  LESIONS. 

Chapter  XX. — Chancre.    Abortion  of  Syphilis  After  Infection 284 

Chapter  XXL— Syphilis    292 

Chapter  XXII.— Treatment  of  Syphilis 327 

Chaptek  XXIIL— Inherited  Syphilis   ' 333 

IMPOTENCE  AND  STERILITY. 
Chapter  XXIV. — Impotence.    Sterility 345 

List  of  Genito-urinary  Instruments  Required  for  Office  Use 363 

Index   365 


LIST  OF  ILLUSTRATIONS. 


PAGE 

Colored  Plate.     Pigmentary  Syphilide  and  Alopecia.      (Author's  Case.) 

Frontispiece 

1.  Papillomata — Venereal  Warts.     (Author's  Case.) 9 

2.  Diagram  of  Bladder  and  Urethra 17 

3.  Diagram  of  Bladder  and  Urethra 19 

4.  Gonorrhoeal    Conjunctivitis    24 

5.  Gonorrhoeal   Pus    27 

6.  Gonococci  Growing  in  Clusters 28 

I.     Section  of  Chancroid facing  30 

II.     Acute   Gonorrhoea    facing  30 

7.  Valentine's  Irrigator   3(5 

8.  Ultzmanns  Syringe    ' 45 

9.  Diagram  of  a  Cross-section  of  the  Urethra,  Kepresenting  the  Histo- 

logical Changes  in  Chronic  Ui'ethritis 47 

10.  Diagram  of  a  Section  of  the  Urethra,  Hepresenting  the  Histological 
Changes  in  the  Formation  of  a  Granular  Patch  in  Chronic  Ure- 
thritis     49 

Gonorrhoeal  Rheumatism  facing  50 

Beginning  Stricture   facing  50 

Shred  from  a  case  of  Gonorrhoea  of  long  standing 52 

Otis  Urethrometer 53 

Diagram  showing  method  of  detecting  Deep  Infiltration  in  Chronic 

Urethritis,  with  Bougie  Jl  Boule  or  Urethrometer 53 

Diagram  showing  impossibility  of  recognizing  Superficial  Infiltration, 
involving  Mucous  Membrane  alone,  by  means  of  Bougie  a  Boule 

or  Urethrometer   53 

Guyon's  Syringe 50 

Steel  Sound  with  Van  Buren  Curve 59 

Psychrophor,  or  Cold-Water  Sound,  of  Wintemitz 05 

Klotz  Endoscope   09 

Urethroscopic  picture  of  a  Normal  Urethra,  showing  a  multitude  of 

fine  folds  and  small  Central  Figure 70 

Urethroscopic  picture  of  Soft  Infiltration  of  the  Mucous  and  Sub- 
mucous Tissues   71 

Urethroscopic  picture  of  Hard  Infiltration  of  the  Submucous  Tissues.  72 

Periurethral  Abscess,  beginning  as  a  Folliculitis.     (Author's  Case.) . .  77 

Horand-Langlebert  Suspensory  Bandage 80 

Benique  Sound  89 

(ix) 


X  LIST   OF  ILLUSTRATIONS. 

PAGE 

25.  Diagram  of  the  Seminal  Vesicles.  The  Right  Vesicle  has  been  Dis- 
sected, and  its  Convolutions  Drawn  Out  Straight 93 

20.  Microscopic  examination  of  material  expressed  from  Seminal  Vesicles 
and  Prostate,  showing  Spermatozoa,  Pus-cells,  and  Boettscher's 

Crystals    95 

27.  Linear  Stricture • 10-t 

28.  Annular  Stricture   lOo 

29.  Changes  behind  a  Stricture.    Dilatation  of  pouch  immediately  behind 

Stricture.    Hypertrophy  and  Contraction  of  Bladder.    Dilatation 

of  Ureter  and  Kidney  (Hydronephrosis) 106 

30.  Flexible  Bougie  a  Boule lOS 

31.  Metal  Bougies  a  Boule 109 

32.  Filiform  Whalebone  Guides 109 

33.  Stricture  of  the  Bulbo-membranous  Uiethra  and  False  Passage Ill 

34.  Tunneled  Sound 117 

35.  Gouley's  Tunneled  Catheter  117 

30.     Otis  Urethrotome,  as  Modified  by  Rand 119 

37.  Maisonneuve's  Urethrotome 120 

38.  Rand's  Tunneled  Sound ." 122 

39.  Gouley's  Catheter-staff    122 

40.  Tunneled  Knife    122 

41.  Gorget    122 

42.  External  Urethrotomy.     Wheelhouse  Operation,  Exposing  the  Ure- 

thra   ". 123 

43.  Wheelhouse  Staff 123 

44.  Small  Tenaculum   for  Holding  Apart  Incised  Urethia   in   External 

Urethrotomy     124 

45.  Arnott's  Grooved  Probe 124 

4G.     Gouley's  Beaked  Bistouiy   124 

47.  Straight  Steel  Sound  ." 125 

48.  Formation  of  a  Sacculation  in  a  hypertrophied  Bladder  from  Pro- 

static enlargement  and  prolonged  Cystitis 140 

49.  Carcinoma  of  the  Bladder 156 

50.  Oxalic  or  Mulberry  Calculus.     (Author's  Specimen.) 161 

51.  Vesical  Calculus,  split  in  two  Halves,  showing  mode  of  formation,  by 

a  deposit  of  Phosphates  in  Concentric  Layers,  around  a  Uric- 
Acid  Nucleus.     (Author's  Specimen.)    161 

52.  Multiple  Phosphatic  Calculi,  removed  by  Suprapubic  Cystotomy  from 

same  Patient.     (Author's  Specimen.)    163 

53.  Calculi  which  formed  in  the  Bladder  as  a  Single  Stone,  which  under- 

went Spontaneous  Fracture.     (Author's  Specimen.) 163 

54.  Thompson's  Searcher  for  Vesical  Calculus 166 

55.  Searching  for  Stone  Lying  in  the  Post-prostatic  Pouch 167 

56.  Nitze's  Observation  Cystoscope    168 

57.  Bigelow's  Lithotrite   171 

58.  Method  of  Grasping  the  Stone  in  Lithotrity 171 

59.  Bigelow's  Evacuator 172 


LIST  OF  ILLUSTRATIONS.  xi 

PAGE 

Lithotomy-staff   174 

Lithotomy-knife     174 

Lithotomy-forceps  175 

Blizaid"s  Probe-Pointed  Knife 175 

Incision  Through  tlie  Urethra  and  Prostate  in  Lateral  Lithotomy...  175 

Lithotomy-scoop    176 

Prostatic  Hypertrophy.    Median  Enlargement,  in  the  form  of  a  Bar. 
Suitable  for  Bottini's  Operation.    A  large  Bladder.     (By  Courtesy 

of  Dr.  F.  S.  Watson.) 183 

Prostatic  Hypertrophy;     Enlargement  of  Lateral  Lobes  and  Median 
Portion.    Bladder  Contracted  and  Non-distensible.     (By  Courtesy 

of  Dr.  F.  S.  Watson.) 185 

Prostatic  Hypertrophy.    Enlargement  of  Lateral  and  Median  Lobes. 

Deep  Post-prostatic  Pouch.     (By  Courtesy  of  Dr.  F.  S.  Watson.)  .  187 
Prostatic   Hypertrophy.     Enlargement   of  the   Lateral   Lobes,   with 
Increase  in  Size  of  the  Median  Portion,  Forming  a  Bar,  Through 

Which  a  False  Passage  has  been  Made 189 

Prostatic  Hypertrophy.    Pedunculated  Middle  Lobe  Obstructing  Pas- 
sage of  a  Catheter 190 

Mercier  Catheter  Coude   200 

Bottini's  Instrument,  as  Modified  by  Freudenberg. 203 

Tuberculovis  Pyelonephritis    234 

Nitze's  Cystoscope  for  Catheterizing  the  Ureters 237 

Hydronephrotic  Kidney  without  much  enlargement 239 

Testicle  and  Epididymis  Exposed  by  Cutting  away  Part  of  the  Tunica 

Vaginalis   ,. . .  .  243 

Hernia  or  Fungus  Testis 248 

Hydrocele.      (Author's  Case.) 257 

Vertical  Section  of  Simple  Hydrocele 259 

Hydrocele  Complicated  by  Hernia 260 

Tapping  a  Hydrocele 2(51 

Varicocele.     (Author's  Case.)    267 

Section  of  Chancroid,  showing  Ducrey's  Bacillus 271 

Chancroids  of  the  Prepuce.     (Author's  Case.) 273 

Taylor's  Flat-Billed  Syringe  for  Washing  Out  the  Balano-preputial 

Sac     '. 278 

86.  Dorsal  Incision  through  Prepuce  to  expose  Chancroids 279 

V.     Section  of  a  Chancre   (Injected) facing  286 

VI.     Section  through  a  Papular  Syphilids facing  286 

Colored   Plate.     Condylomata   Lata,   or    Syphilitic  Papules   around   the 

Anus.     (Author's  Case.)    facing  297 

87.  Circinate  Syphilide.     An  Early  Secondary  lesion,  and  variety  of  the 

Macular  form  of  Syphilide.     (Author's  Case.) 301 

88.  Large  Papular  Syphilide.     (Courtesy  of  Dr.  Colby.) 303 

89.  Malignant  Syphilis.     Pustular  Eruption.     (Author's  Case.) 305 

VII.     Gumma  of  the  Testicle facmg  308 

VIII.     Endarteritis  (Artery  from  the  Fissue  of  Sylvius) facing  308 


xii  LIST  OF  ILLUSTRATIONS. 

PAGE 

90.  Gummata  of  the  Tongue.     The  one  in   the  middle  has  undergone 

Coagulation-necrosis  of  its  centre.     (Author's  Case.) 311 

91.  Ulcerating  Gumma  of  the  Ankle.     (Author's  Case.) 311 

92.  Rupial  Syphilide.     (Author's  Case.) 315 

93.  Pustular  Syphide  (Malignant  Syphilis).     (Author's  Case.) 317 

Colored  Plate.    Diy  or  Atrophic  Tubercular  Syphilide.      (Author's   Case.) 

facing     334 

94.  Hutchinson's  Teeth.     These  Teeth  have  been  recently  cut,  and  the 

Central  Notch  is  well  outlined,  but  the  thin  and  unprotected 

dentine  has  not  yet  crumbled  away 341 

95  and  9G.     Hutchinson's   Teeth,   showing   Later   Stages   of  the   Process 

after  the  Dentine  has  been  destroyed 341 


DISEASES  OF  THE  PENIS^ 


CHAPTER   L 

PHIMOSIS. 

By  the  term  phimosis  is  understood  an  abnormal  narrowing 
of  the  opening  of  the  prepuce,  which  prevents  the  retraction  of 
the  foreskin  and  causes  the  glans  penis  to  be  permanently  covered. 

Phimosis  may  be  congenital  or  may  be  acquired  in  adult  life. 

In  nearly  all  male  children  at  birth  the  foreskin  is  long  and  is 
adherent  to  the  glans.  In  early  life  these  adhesions  are  very  weak 
and  are  easily  ruptured  by  erections  of  the  penis  or  manipulation, 
and  in  the  course  of  the  first  few  years  the  preputial  orifice  becomes 
enlarged  and  the  prepuce  can  be  stripped  back  over  the  glans.  If 
the  adhesions  are  not  ruptured  early,  they  become  firmer  as  they 
grow  older,  and  prevent  the  complete  retraction  of  the  foreskin. 

The  acquired  form  of  phimosis  occurs  in  adults,  and  often  re- 
sults from  the  cicatricial  contraction  of  the  margin  of  the  prepuce 
following  the  healing  of  a  chancroid  in  this  location. 

Temporary  phimosis  often  results  from  the  swelling  and  oedema 
of  the  prepuce  which  occurs  in  the  course  of  an  attack  of  gonorrhoea 
or  subpreputial  chancroids. 

As  direct  results  of  phimosis  the  following  conditions  are  met 
with : — 

{a)  Balanitis  and  venereal  ivarts,  resulting  from  the  maceration 
of  the  epithelium  in  the  balano-preputial  sac,  from  retention  of 
smegma  and  urine.  On  account  of  the  difficulty  of  retracting  the 
prepuce,  proper  cleanliness  cannot  be  observed,  and  the  tender 
mucous  membrane  is  especially  'liable  to  persistent  and  recurrent 
attacks  of  inflammation.  Proliferation  of  the  epithelial  cells  occurs, 
and  venereal  warts  grow  luxuriantly. 

(5)  Preputial  calculi,  or  concretions,  form  not  infrequently,  from 
a  calcification  of  the  smegma  and  the  decomposition  of  the  urinary 
salts. 

(1) 


2  DISEASES  OF  THE  PENIS. 

(c)  Epithelioma  of  the  penis  is  strongly  predisposed  to  by  the 
continued  irritation  of  the  foreskin  and  retained  secretions  under  it. 

(d)  Arrested  development  of  the  penis  usually  occurs  in  conse- 
quence of  the  malnutrition  from  which  the  organ  suffers. 

(e)  Premature  erections  and  sexual  excitement  are  generally  noted 
in  young  children  affected  with  phimosis,  and  the  continued  irrita- 
tion about  the  head  of  the  penis  often  establishes  a  habit  of  mastv/r- 
bation. 

(f)  Interference  with  the  act  of  coitus,  often  accompanied  by 
premature  ejaculation,  is  frequently  complained  of  by  adults  affected 
with  phimosis. 

(g)  Liability  to  infection  with  syphilis  or  chancroidal  poison  is 
invariably  the  case  when  the  prepuce  is  long,  even  though  it  can 
be  retracted,  and  Hutchinson  points  out  that  the  circumcised  Jew  is 
less  liable  to  contract  syphilis  than  an  uncircumcised  person,  because 
after  circumcision  the  integument  of  the  glans  becomes  horny,  and 
not  liable  to  abrasions. 

The  remote  results  of  phimosis  are  equally  important,  and  often 
present  great  difficulties  in  the  exact  determination  of  their  origin. 

(a)  Reientian  or  incontinence  of  urine,  especially  in  children,  but 
sometimes  in  adults,  is  often  caused  by  a  spasmodic  contraction  of 
the  cut-off  muscle  or  an  irritable  bladder,  induced  by  the  irritation 
about  the  glans  penis. 

{b)  Hoimorrhoids,  prolapsus  ani,  hernia,  and  dilatation  of  the 
ureters  and  hidney  pelves  often  follow  the  prolonged  and  violent 
straining  efforts  which  individuals  affected  with  phimosis  make,  upon 
urinating,  in  order  to  overcome  the  resistance  offered  by  a  spasmodic 
stricture  or  a  pin-point  opening  through  the  prepuce.  The  sus- 
ceptible nervous  system  of  children  renders  them  particularly  liable 
to  the  above-mentioned  diflliculties  and  also  to  the  following  affec- 
tions:— 

(c)  Affections  of  the  nervous  system, — spastic  palsies,  simulated 
hip-joint  disease,  muscular  inco-ordination,  and  convulsions, — which 
are  often  observed  in  young  children  as  reflexes  from  a  tight  or 
adherent  prepuce,  and  a  disappearance  of  these  symptoms  often 
follows  circumcision. 

(d)  Herpes  prceputialis  is  another  manifestation  of  the  reflex 
action  upon  the  nervous  system  and  skin  of  the  prepuce  occasioned 
by  the  irritation  of  a  long  foreskin,  even  though  it  is  possible  to 
retract  it  over  the  glans. 


PHIMOSIS.  3 

TREATMENT. 

On  account  of  the  manifold  advantages  offered  by  an  absence 
of  the  foreskin,  it  would  be  well  if  Christian  nations  were  to  adopt 
the  old  Hebrew  rite  of  circumcising  all  male  children  on  the  eighth 
day  after  birth.  In  this  operation  the  foreskin  is  simply  snipped 
off  with  one  sweep  of  a  knife,  and  the  wound  washed  with  a  weak 
astringent  antiseptic.  The  pain  is  slight,  and  an  anaesthetic  is  not 
required,  nor  would  it  be  safe  to  administer  one  in  so  young  a  child. 
Hsemorrhage  is  trifling,  and  there  is  but  little  risk  of  infection  after- 
ward. 

Stripping  back  the  foreskin  and  breaking  up  the  adhesions  is 
sometimes  recommended,  but  is  a  very  poor  makeshift  for  circum- 
cision, and  there  is  always  the  danger  of  the  prepuce  being  caught 
back  behind  the  glans,  and  becoming  swollen  and  constricted,  caus- 
ing paraphimosis. 

Circumcision  is  the  operation  of  choice,  and  may  be  performed 
in  two  ways: — 

(a)  Circumcision  with  a  Clamp. — In  this  operation  the  clamp 
is  applied  to  the  foreskin  immediately  below  the  glans  penis,  and 
all  the  prepuce  which  projects  beyond  the  clamp  is  severed  with 
a  knife  or  scissors.  This  incision  simply  cuts  through  the  skin  alone, 
and  the  mucous  membrane  lying  next  the  glans  is  left  intact  and 
must  next  be  trimmed  off  with  the  scissors.  After  this  is  done  the 
cut  edges  of  skin  and  mucous  membrane  are  stitched  together  with 
interrupted  sutures  of  catgut,  and  the  operation  is  completed. 

There  are  certain  objections  to  this  procedure.  In  applying  the 
clamp,  if  too  much  traction  is  made  on  the  foreskin,  the  skin  of  the 
proximal  end  retracts  close  up  to  the  root  of  the  penis  after  the 
incision  is  made,  and  leaves  a  gaping  raw  surface  of  mucous  mem- 
brane to  be  covered.  On  the  other  hand,  if  too  much  foreskin  is  left, 
the  glans  remains  covered  by  it  and  the  object  for  which  the  opera- 
tion was  performed  is  not  accomplished.  Even  when  the  incision  is 
properly  made  the  subsequent  adjustment  of  skin  and  mucous  mem- 
brane often  induces  a  certain  amount  of  tension  and  dragging  upon 
the  sutures,  which  interferes  with  the  healing  of  the  wound.  For 
these  reasons  the  author  prefers  the  operation  of 

(b)  Circumcision  by  Dorsal  Incision  and  Trimming  off  the 
Flaps. — The  surgeon  stands  upon  the  patient's  left  side  and  with 
a  pair  of  straight  scissors  makes  an  incision  on  the  dorsum  of  the 
prepuce,  cutting  through  skin  and  mucous  membrane  at  the  same 


4  DISEASES  OF  THE  PENIS. 

time.  The  incision  is  carried  up  to  the  point  where  the  mucous 
membrane  is  reflected  upon  the  glans  penis.  A  grooved  director 
may  be  introduced  under  the  foreskin  if  desired,  to  act  as  a  guide 
for  the  scissors. 

After  the  dorsal  incision  is  made  the  two  remaining  flaps  of 
skin  and  mucous  membrane  are  trimmed  off  with  curved  scissors. 
This  incision  is  carried  around  the  penis  on  both  sides,  following  the 
line  of  insertion  of  the  mucous  membrane  at  a  distance  of  one- 
eighth  of  an  inch  from  the  glans. 

The  fraenum  is  divided  last,  and  its  artery,  together  with  the 
dorsal  artery,  and  sometimes  one  or  two  smaller  ones,  are  picked 
up  and  tied,  and  the  sutures  are  introduced. 

It  is  desirable  to  place  the  first  suture  on  the  dorsum  of  the 
penis,  and  the  second  suture  stitches  the  remains  of  the  frjEnum  to 
the  point  of  skin  underneath  it.  These  anchor  the  skin  and  prevent 
it  from  shifting,  as  it  lies  on  the  mucous  membrane.  The  other 
sutures  are  then  introduced,  and  usually  three  on  a  side  will  be 
found  enough.  Fine  catgut  is  the  best  material,  as  it  is  absorbed, 
while  if  silk  sutures  are  used  much  trouble  is  experienced  in  remov- 
ing them. 

The  best  form  of  dressing  seems  to  be  a  piece  of  lint  wet  with  an 
antiseptic  solution  and  changed  frequently,  as  any  sort  of  permanent 
dressing  is  soon  soaked  with  urine.  The  patient  should  remain 
quietly  in  bed  or  on  a  lounge,  for  a  week,  and  may  be  then  allowed 
to  go  about  as  usual. 

With  regard  to  the  ansesthetic  used,  the  operation  may  be  done 
painlessly  with  cocaine,  injected  hypodermically  under  the  skin  of 
the  penis  along  the  line  of  incision,  and  in  order  to  anaesthetize  the 
mucous  membrane  '^'/^  drachm  should  be  injected  into  the  balano- 
preputial  sac  and  held  there  for  five  minutes.  The  oedema  of  the 
cellular  tissue  resulting  from  tying  a  rubber  bandage  around  the 
root  of  the  penis  to  prevent  the  too  rapid  absorption  of  the  cocaine 
interferes  with  the  best  healing  of  the  wound  afterward,  and  on 
that  account  the  author  prefers  to  administer  a  general  anaesthetic. 
A  better  result  will  be  obtained  if  the  patient  is  kept  in  bed  for  a 
few  days  following  the  operation  than  if  allowed  to  be  up  and  about 
his  room. 


BALANO-POSTHITIS. 


BAIANO-POSTHITIS. 


Balanitis  consists  in  an  inflammation  of  the  mucous  membrane 
covering  the  glans  penis,  and  an  inflammation  affecting  tlie  mucous 
layer  of  the  prepuce  is  termed  posthitis.  The  inflammation  of  both 
surfaces  usually  exists  simultaneously,  and  should  be  considered 
together. 

Balano-posthitis  cannot  occur  in  an  individual  who  has  been 
circumcised,  but  the  presence  of  a  long  and  phimotic  foreskin  allows 
the  retention  of  the  natural  secretion  of  smegma  and  a  few  drops 
of  urine,  which  decompose  and  irritate  the  already  macerated  mucoiis 
membrane,  lowering  its  power  of  resistance  to  germ-infection. 

Gouty  and  lithaBmic  conditions  and  diabetes  also  render  the 
patient  extremely  liable  to  develop  inflammation  of  the  mucous 
membrane  underneath  a  long  foreskin. 

As  a  direct  exciting  cause  it  is  probably  necessary  that  micro- 
organisms of  some  sort  must  be  inoculated,  and  for  this  reason  a 
balano-posthitis  often  develops  from  contact  with  irritating  vaginal 
secretions  in  coitus  or  the  accidental  introduction  of  pyogenic  organ- 
isms from  contact  with  the  hands  or  clothing. 

Chancre,  gonorrhoea,  and  chancroid  are  apt  to  be  complicated 
by  balano-posthitis  as  a  result  of  mixed  infection,  when  they  occur  in 
an  individual  havin^  a  long  foreskin. 


SYMPTOMS  AND  COURSE. 

A  mild  form  of  balano-posthitis  is  liable  to  occur  at  frequent 
intervals  unless  the  man  with  a  long  foreskin  attends  with  scrupulous 
care  to  drawing  it  back  and  washing  it,  and  the  preputial  sac,  at 
frequent  intervals. 

If  this  is  not  done,  a  sense  of  heat  and  itching  is  noticed  at  the 
end  of  the  penis;  the  mucous  membrane  becomes  hyperaemic,  in- 
filtrated, and  eroded;  and  a  creamy-yellow,  purulent  discharge,  with 
an  extremely  offensive  odor,  is  secreted  from  the  mucous  membrane 
of  the  preputial  sac. 

In  severe  cases  the  excoriations  are  extensive  and  well  marked 
and  the  inflammation  and  oedema  are  extreme;  so  that  the  whole 
prepuce  becomes  swollen.  In  this  condition  gangrene  of  the  foreskin, 
either  in  part  or  as  a  whole,  not  infrequently  takes  place. 


6  DISEASES  OF  THE  PENIS. 

DIAGNOSIS. 

The  diagnosis  of  balano-posthitis  presents  but  little  difficulty, 
when  the  foreskin  can  be  retracted  and  the  glans  inspected;  but 
when  phimosis  exists  the  diagnosis  is  often  perplexing. 

If  a  microscopic  examination  of  the  discharge  fails  to  reveal 
gonococci,  but  discloses  numerous  staphylococci,  gonorrhoea  may  be 
excluded. 

Chancroid  may  be  diagnosed  by  inoculating  some  of  the  pre- 
putial discharge  upon  the  patient's  thigh,  and,  if  other  chancroids 
are  caused,  it  is  probable  that  the  original  sore  was  a  chancroid, 
although  it  is  possible  to  cause  sores  resembling  chancroids  by  the 
inoculation  of  staphylococci. 

Chancre  can  be  excluded  by  the  absence  of  an  indurated  mass 
under  the  prepuce  and  the  lack  of  the  characteristic  enlargement 
in  the  inguinal  glands. 

Epithelioma  is  often  difficult  to  differentiate  from  the  chronic 
form  of  balano-posthitis  which  affects  middle-aged  men;  but  epi- 
thelioma does  not  respond  to  local  treatment,  while  balanitis  im- 
proves quickly.  rEn  cases  of  doubt  it  is  always  in  order  to  excise 
a  small  portion  of  the  prepuce  and  subject  it  to  microscopic  exami- 
nation to  determine  the  question. 

TREATMENT, 

The  essential  points  in  the  treatment  are  to  keep  the  parts 
clean  and  dry.  These  indications  can  be  met  in  the  following 
manner: — 

In  the  cases  when  the  prepuce  can  he  retracted,  the  ^balano- 
preputial  sac  should  be  washed  out  with  a  mild  antiseptic  solution, 
either  bichloride  (1  in  10,000  to  1  in  4000)  or  Thiersch's  fluid.  The 
parts  should  then  be  dried  and  covered  with  a  dusting-powder: — 

IJ  Pulv.  amyli, 
Pulv.  zinci  oxidi, 
Pulv.   talei aa  3ij. 

Or:— 

IJ  Hydrarg.  chlor.  mite ar.  xxx. 

Aeidi  borici gr.  xv. 

Acidi  salicylici gr.  v. 

In  chronic  cases,  occurring  in  elderly  men,  subgallate  of  bismuth 
has  a  particularly  good  effect. 


BALANO-POSTHITIS.  7 

After  applying  the  dusting-powder  the  glans  should  be  covered 
with  a  layer  of  cotton  and  the  foreskin  drawn  forward  into  place. 
This  dressing  should  be  changed  several  times  a  day. 

If  the  erosions  are  deep  and  extensive,  their  healing  can  be 
hastened  by  brushing  them  over  with  a  10-per-cent.  nitrate-of-silver 
solution  before  applying  the  dusting-powder. 

When  phimosis  exists  and  the  foreskin  cannot  be  retracted,  a  long, 
flat-billed  syringe  should  be  used  for  washing  out  the  balano- 
preputial  sac,  every  few  hours. 

A  few  syringefuls  of  warm  water  and  soap  may  be  thrown  in 
and  followed  by  injecting  bichloride  solution  (1  in  10,000)  or 
Thiersch's  fluid. 

The  oedema  and  swelling  of  the  parts  may  be  mitigated  by  pro- 
longed soaking  in  hot  water. 

If  the  balanitis  occurs  as  a  result  of  diabetes  or  a  subpreputial 
chancroid,  it  may  be  necessary  to  relieve  the  tension  by  slitting  up 
the  prepuce  on  the  dorsum  in  order  to  avert  impending  gangrene. 

In  all  cases  of  chronic  or  relapsing  balano-posthitis,  in  addition 
to  local  measures,  attention  should  be  directed  to  the  diathetic  con- 
ditions which  prevent  a  permanent  healing.  If  the  individual  is 
gouty  or  diabetic,  a  suitable  regimen  should  be  adopted,  and  the 
general  health  carefully  looked  after. 

In  obstinate  cases  of  balano-posthitis,  circumcision  should  be 
performed  as  soon  as  the  acute  symptoms  have  subsided.  This  is 
especially  necessary  in  elderly  men,  who  are  at  an  age  when  epi- 
thelioma is  liable  to  develop  on  the  glans  or  under  the  prepuce  from 
the  prolonged  irritation  of  the  parts. 

In  diabetic  patients  the  operation  of  circumcision  should  be 
avoided  if  possible  and  the  danger  of  extensive  gangrene  following 
slight  operations  should  be  borne  in  mind.  If  any  operative  pro- 
cedure is  demanded,  it  is  of  the  highest  importance  to  get  the  pa- 
tient's urine  in  good  condition  before  operating. 


DISEASES  OF  THE  PENIS. 


HERPES  PROGENITALIS. 


This  affection  is  characterized  by  the  formation  of  groups  of 
small  vesicles  upon  an  erythematous  base  and  located  on  the  skin  or 
mucous  surface  of  the  prepuce. 

The  thin  vesicles  are  easily  ruptured,  and  leave  small,  round, 
shallow,  punched-out  ulcers,  which  heal  spontaneously  in  a  few  days. 

Unlike  herpes  zoster,  herpes  progenitalis  is  generally  unaccom- 
panied with  pain.  In  exceptional  cases,  however,  pain  is  felt,  which 
is  neuralgic  in  character  and  precedes  the  appearance  of  the  erup- 
tion. 

A  urethral  discharge  is  sometimes  observed,  and  endoscopic 
examination  shows  a  collection  of  vesicles  located  within  the  urethra. 

Recurrence  is  a  marked  characteristic  of  herpes  progenitalis, 
and  it  is  the  rule  for  patients  to  have  several  attacks  a  year. 


ETIOLOGY. 

Herpes  progenitalis  may  be  regarded  as  a  reflex  manifestation 
of  some  irritation  of  the  nerves  supplying  the  genitals,  and  is  usually 
due  to  balano-posthitis,  excessive  coitus,  or  a  long  prepuce.  Gouty 
and  lithgemic  conditions  are  thought  to  predispose  the  patient  to 
attacks  of  herpes. 

DIAGNOSIS. 

If  the  case  is  seen  early,  the  appearance  of  the  vesicles  is  un- 
mistakable, and  after  they  have  ruptured  the  small,  round,  punched- 
out  ulcers  are  quite  characteristic. 

The  lymphatic  glands  in  the  groin  are  usually  not  affected,  but 
in  one  case  in  ten  the  inguinal  glands  are  said  to  be  enlarged  in 
a  chain,  as  in  syphilis.    (J.  W.  White.) 


TREATMENT. 

The  herpetic  lesions  rapidly  heal  with  cleanliness  and  the  appli- 
cation of  a  simple  absorbent  dusting-powder.  Recurrent  herpes 
progenitalis,  which  almost  always  occurs  in  connection  with  a  long 
foreskin,  can  only  be  prevented  by  the  operation  of  circumcision. 


Fig.  1. — Papillomata — Venereal  Warts.     (Author's  Case,  from 
Kings  County  Hospital.) 


(9) 


PAPILLOMATA.  H 


PAPILLOMATA. 

Papillomata  occurring  about  the  head  of  the  penis  are  fre- 
quently termed  venereal  warts.  They  are  sometimes  spoken  of  as 
condylomata,  which  is  manifestly  incorrect,  as  true  condylomata  are 
a  manifestation  of  syphilis,  and  the  papillomata  have  no  connection 
with  syphilis,  but  are  of  purely  local  origin. 

Papillomata  consist  in  warty  growths,  which  are  flat  or  often 
cauliflower-like  excrescences,  usually  located  in  the  coronary  sulcus 
under  a  long  prepuce.  In  structure  they  are  a  simple  hypertrophy 
of  the  papillary  layer,  and  are  caused  by  the  prolonged  maceration 
and  softening  of  the  mucous  surfaces  under  a  long  foreskin,  occa- 
sioned by  contact  with  irritating  discharges  from  gonorrhoea,  chan- 
croids, or  balano-posthitis. 

DIAGNOSIS. 

Papillomata  may  be  mistaken  for  the  condylomata  of  syphilis 
or  epithelioma.  In  syphilitic  condylomata,  however,  other  signs  of 
specific  disease  are  always  present;  but  epithelioma  may  be  difficult 
to  differentiate  from  simple  papillomata,  and  every  warty  growth 
occurring  about  the  glans  penis  in  elderly  men  should  be  regarded 
with  suspicion. 

TREATMENT. 

Small  warts  sometimes  disappear  if  the  parts  are  kept  clean  and 
covered  with  a  dusting-powder;  but  their  disappearance  is  a  matter 
of  uncertainty,  and  always  very  slow.  Operation  is  the  best  treat- 
ment, and  should  always  be  advised. 

As  papillomata  occur  in  consequence  of  a  long  foreskin,  circum- 
cision should  be  performed,  and  the  warts  which  are  not  removed 
with  the  prepuce  scraped  off  with  a  sharp  curette.  In  order  to  pre- 
vent a  recurrence,  it  is  desirable  to  cauterize  the  bases  with  nitric  or 
carbolic  acid  or  the  Paquelin  cautery. 


13  DISEASES  OF  THE  PENIS. 

CANCER  OF  THE  PENIS. 

Malignant  disease  of  the  penis  occurs  almost  invariably  as 
epithelial  carcinoma,  and  begins  with  about  equal  frequency  on  the 
inner  surface  of  the  prepuce  or  upon  the  glans. 

According  to  Jacobson,  its  mode  of  commencement  is  varied, 
but  it  appears  most  frequently  as:  (a)  A  ivart,  or  warty  excrescence. 
Sometimes,  however,  it  makes  its  appearance  as:  (6)  A  small  nodule, 
or  Tcnot  of  induration,  under  the  surface  of  the  mucous  membrane. 

Again,  epithelioma  is  observed  occurring  under  the  form  of 
(c)  a  superficial  excoriation,  or  raw  patch,  resembling  the  erosions 
found  in  balano-posthitis;  or  it  may  develop  as  {d)  an  ulcer  resulting 
from  the  transformation  of  a  chancroid  or  the  breaking  down  of  an 
old  cicatrix,  or  sometimes  from  a  crack  or  tear  on  the  margin  of 
a  tight  foreskin. 

In  cases  of  extreme  rarity  epithelioma  of  the  penis  develops 
from-  the  extension  of  the  malignant  process  outward  from  the  urethra 
or  upward  from  the  scrotum. 

ETIOLOGY. 

Under  the  head  of  predisposing  causes  age  plays  an  important 
role,  and  epithelioma  of  the  penis  is  very  rarely  found  except  be- 
tween the  fiftieth  and  seventieth  years. 

The  next  most  important  predisposing  cause  is  phimosis.  De- 
marquay  found  that  out  of  fifty-nine  cases  of  epithelioma  of  the 
penis,  forty-two  had  long  and  phimotic  foreskins,  and  many  authors 
have  called  attention  to  the  fact  that  the  circumcised  Jews  are  almost 
entirely  free  from  this  disease. 

Even  though  the  glans  be  covered  with  a  long  foreskin,  if  the 
individual  attends  to  the  daily  cleansing  of  the  balano-preputial  sac 
there  is  no  opportunity  for  irritating  secretions  to  be  retained;  but 
we  notice  that  cancer  of  the  penis  almost  always  occurs  in  men  in 
the  lower  walks  of  life,  of  neglectful  and  uncleanly  personal  habits. 

Any  condition  which  gives  rise  to  a  balano-posthitis,  such  as 
the  retention  of  decomposed  smegma  and  urine  under  a  phimotic 
foreskin,  particularly  if  aggravated  by  a  gouty  diathesis  in  the  pa- 
tient, excites  a  persistent  and  long-continued  irritation.  In  an 
elderly  person  in  course  of  time  the  simple  inflammatory  process 
undergoes  a  transition  into  carcinoma  of  a  polymorphous  type,  com- 
posed of  large  pavement-cells  and  small  epithelial  cells. 


CANCER  OF  THE  PENIS.  13 

COURSE. 

No  matter  in  what  form  the  disease  had  its  origin,  its  course 
is  one  of  extension  at  the  edges,  accompanied  by  ulceration  and 
breaking  down  in  the  older  parts,  and  in  most  cases  this  is  attended 
by  the  formation  of  large  vegetations,  or  fungosities,  resembling  a 
cauliflower  in  shape. 

A  thin  fluid,  of  a  most  disgusting  odor,  which  dries  into  scabs, 
is  continually  secreted. 

As  the  cancerous  process  extends  only  by  continuity,  its  advance 
through  the  corpora  cavernosa  is  not  rapid,  but  the  lymphatics 
readily  take  up  the  infectious  material,  carry  it  to  the  glands  in  the 
groin,  and  these  are  usually  involved  quite  early  in  the  disease. 

The  inguinal  lymphatic  glands  are  often  the  seat  of  a  mixed 
infection,  if  pyogenic  bacteria  have  been  conveyed  to  them  through 
the  lymphatics  and  cause  them  to  become  inflamed  and  suppurate. 

DIAGNOSIS. 

Every  warty  or  papillomatous  growth,  or-  persistent  erosion 
occurring  on  the  glans  penis,  or  inner  surface  of  the  prepuce,  in  an 
elderly  person,  should  always  be  regarded  with  grave  suspicion. 

It  is  often  difficult  to  differentiate  simple  papillomata  or  a 
chronic  balano-posthitis  from  carcinoma,  but  the  age  gf  the  patient, 
the  long,  protracted  duration  of  the  sore,  together  with  a  base  which 
is  hard,  infiltrated,  and  immovable,  and  an  edge  which  is  hard  and 
infiltrated,  would  point  strongly  in  the  direction  of  epithelial  car- 
cinoma. The  diagnosis  could  be  definitely  determined  by  cutting  a 
small  piece  from  the  growth  and  subjecting  it  to  microscopic  exami- 
nation. 

A  gumma  of  the  penis  occurring  in  tertiary  syphilis  might  be 
easily  mistaken  for  epithelioma;  but  a  few  w^eeks'  treatment  with 
mercury  and  iodides  would  cause  the  gumma  to  disappear. 

PROGNOSIS. 

The  prognosis  of  epithelioma  of  the  penis  is,  of  course,  fatal 
without  operation,  and  death  occurs  in  from  one  to  two  years.  If 
the  disease  is  seen  early  and  the  growth  removed  by  amputation  of 
the  penis  and  extirpation  of  the  groin  glands,  the  prognosis  is  good; 
but  many  cases  come  into  the  hands  of  the  surgeon  too  late  for  a 
complete  removal  of  all  the  foci  of  infection.  Winiwarter  reports 
13  amputations,  of  which  5  remained  permanently  well,  1  died  of 


14  DISEASES  OF  THE  PENIS. 

the  operation,  and  6  had  recurrences,  3  of  which  were  in  the  stump 
and  3  in  the  glands. 

TREATMENT. 

As  already  indicated,  complete  removal  of  all  deposits  at  the 
earliest  possible  moment  offers  the  patient  the  only  opportunity  of 
saving  his  life,  and  the  application  of  caustics  only  excites  greater 
activity  in  the  growth  and  is  a  waste  of  valuable  time. 

Two  forms  of  operation  are  in  use,  and  a  selection  depends  upon 
the  extent  to  which  the  inguinal  glands  and  corpora  cavernosa  are 
involved. 

OPERATIONS. 

Amputation  of  the  Free  Portion  of  the  Penis. — Technique. — A 
No.  20  French  sound  is  introduced  through  the  meatus  into  the 
bladder  to  indicate  the  position  of  the  urethra. 

A  harelip-pin  is  thrust  through  both  corpora  cavernosa,  at  the 
root  of  the  penis,  to  hold  in  place  a  rubber  band,  which  is  made  to 
encircle  the  penis  and  act  as  a  tourniquet. 

The  skin  of  the  penis  is  then  cut  through  with  a  circular  sweep 
of  the  knife,  and  turned  back  an  inch.  The  corpora  cavernosa  are 
divided,  down  to  the  corpus  spongiosum,  which,  with  the  urethra,  is 
left  to  project  like  a  spout  for  an  inch,  before  being  cut  through. 

The  tourniquet  is  then  unloosed  and  at  least  four  arteries  will 
require  ligation.  The  skin-flaps  are  sutured  together,  and  the  urethra 
stitched  to  the  margins  of  the  skin-flaps. 

A  soft-rubber  catheter  is  tied  in  the  bladder  to  prevent  the 
urine  from  infecting  the  fresh  wound. 

Amputation  of  the  Entire  Penis. — This  is  a  much  more  serious 
operation  than  the  former,  but  is  demanded  in  the  case  of  extensive 
infiltration  of  the  corpora  cavernosa  with  cancerous  deposit. 

Technique. — The  patient  is  placed  in  the  lithotomy  position,  and 
a  sound  is  introduced  through  the  urethra  into  the  bladder.  An  in- 
cision is  made  along  the  raphe  of  the  scrotum,  splitting  it  into  two 
halves.  The  dissection  is  carried  down  so  that  the  corpus  spongio- 
sum is  seen  perforating  the  triangular  ligament,  with  the  corpora 
cavernosa  lying  on  either  side  and  attached  to  the  rami  of  the  pubes. 

The  corpus  spongiosum,  containing  the  urethra,  is  then  dis- 
sected away  from  the  corpora  cavernosa  for  three  inches,  cut 
through,  and  allowed  to  hang  down  out  of  the  way,  at  the  lower 
angle  of  the  wound. 


CANCER  OF  THE  PENIS.  15 

The  next  step  is  to  separate  the  corpora  cavernosa  from  their 
attachments  to  the  rami  of  the  pubes.  It  is  generally  recommended 
that  this  should  be  done  with  a  periosteal  elevator.  The  close  attach- 
ment to  the  bones  renders  this  a  matter  of  considerable  difficulty, 
and  after  separation  there  is  a  free  haemorrhage,  which  is  difficult  to 
control. 

The  author  prefers  to  burn  through  the  crura  penis  with  a 
Paquelin  cautery  close  to  their  attachments  to  the  bone,  and  in  this 
way  the  corpora  cavernosa  are  readily  freed  from  the  pubes  and 
without  haemorrhage.  The  Paquelin  can  also  be  used  to  stop  bleed- 
ing, which  generally  occurs  from  the  dorsal  vessels  of  the  penis  under 
the  symphysis  pubfs,  at  the  upper  angle  of  the  wound. 

The  final  steps  of  the  operation  consist  in  bringing  the  urethra 
up  into  the  wound  and  stitching  it  to  the  margins  of  the  skin-flaps, 
and  then  the  skin  on  either  side  is  brought  into  apposition  and 
stitched. 

A  catheter  may  be  carried  through  the  urethra  and  left  in  the 
bladder  to  drain  it. 

In  this  operation  the  testicles  are  exposed  and  may  be  left  in 
the  wound,  or  castration  may  be  performed,  to  quell  the  sexual  desire 
on  the  part  of  the  patient  after  his  recovery. 

The  inguinal  lymphatic  glands  should  be  removed  at  the  time 
any  operation  is  performed  for  the  relief  of  malignant  disease  of  the 
penis,  for  if  the  glands  have  become  infected,  which  occurs  early 
in  the  disease,  a  recurrence  of  the  cancer  will  inevitably  take  place 
later  on. 


DISEASES  OF  THE  URETHRA  AND 
ITS  ADNEXA. 


CHAPTER   IL 

ANATOMY  OF  THE  URETHRA. 

The  urethra  is  a  canal,  open  at  both  ends,  whose  walls  lie  in 
wrinkled  folds  and  come  closely  in  contact  except  when  distended  by 
the  passage  of  urine  or  a  catheter. 

The  length  of  the  canal  from  meatus  urinarius  to  sphincter 
vesicae  is  about  eight  inches  and  it  is  divided  into  three  regions: — 

(a)  The  anterior  or  pendulous  urethra,  which  is  six  inches  in 
length. 

(h)  The  membranous  urethra,  which  is  about  one  inch  long. 

(c)  The  prostatic,  or  posterior,  urethra,  which  is  one  inch  in 
length. 

The  anterior  urethra  is  surrounded  by  the  erectile  tissue  of  the 
corpus  spongiosum,  which  terminates  in  the  bulb.  At  a  point  cor- 
responding to  the  bulb,  in  the  anterior  urethra,  and  lying  between 
the  peno-scrotal  junction  and  the  anterior  layer  of  the  subpubic 
triangular  ligament,  for  a  distance  of  an  inch,  is  a  part  of  the  canal 
which  is  termed  the  bulbous  urethra. 

The  membranous  urethra  is  the  portion  of  the  canal  lying  be- 
tween the  anterior  and  posterior  layers  of  the  triangular  ligament. 
Its  mucous  membrane  is  not  so  richly  supplied  with  mucous  glands 
and  follicles  as  the  other  portions  of  the  urethra,  and  it  acts  as  a 
barrier  to  the  onward  progress  of  a  gonorrhoeal  inflammation. 

The  membranous  urethra  is  surrounded  by  bands  of  voluntary 
muscular  fibres  known  as  the  cut-off  muscle,  or  compressor  urethrce, 
which  is  normally  in  a  state  of  tonic  contraction,  and  acts  as  a  valve 
to  separate  the  anterior  from  the  posterior  urethra. 

Before  the  act  of  urination  the  cut-off  muscle  is  relaxed  in 
order  to  allow  the  urine  to  flow  out  past  it,  and  by  its  voluntary  con- 
traction the  flow  of  urine  can  be  instantly  shut  off. 

The  cut-off  muscle  is  sometimes  affected  by  a  cramp-like  con- 
traction and  fails  to  relax,  causing  retention  of  urine  or  rendering 
(IG) 


Fig.  2. — Diagram  of  Bladder  and  Urethra. 


A,  Interior  of  Bladder. 

B,  Symphysis  Pubis. 

C,  Integument. 

D,  Vas  Deferens. 

E,  Vesieulse  Seminales. 

F,  Prostate  Gland. 

G,  Corpus  Cavernosum. 
H,  Scrotum. 

/,  Verumontanum. 


J ,  Cowper's  Gland. 
K,  Orifice  of  Ejaculatory  Duct. 
L,  Bulb  of  Corpus  Spongiosum. 
M,  Corpus  Spongiosum. 
'N,  Urethra. 
O,  Prepuce. 
P,  Glans  Penis. 
Q,  Suspensory  Ligament. 
/?,  Space  of  Ketzius. 
Peritoneal  Fold. 

(17) 


A,  Bladder  Base. 

B,  Opening  of  Ureters. 

C,  Prostate  Gland. 


Diagram  of  Bladder  and  Urethra. 


D,  Verumontanum. 

E,  Cowper's  Glands. 

F,  Mouth  of  Ducts  from  Cowper's  Glands. 


(19) 


ANATOMY  OF  THE  URETHRA.  21 

it  difficult  or  impossible  to  pass  a  sound.  This  condition  is  known 
as  spasmodic  stricture. 

The  prostatic,  or  posterior,  urethra  perforates  the  prostate  gland. 
It  is  very  richly  supplied  with  mucous  glands  and  follicles.  Upon 
its  floor  is  a  small  elevation  composed  of  erectile  tissue  and  abun- 
dantly supplied  with  nerves,  and  called  the  verumontamim,  or  caput 
gaUinaginis.  At  its  base,  in  front,  is  a  small  depression,  the  sinus 
pocularis,  or  uterus  masculinus.  The  ejaculatory  ducts  and  the  pro- 
static sinuses  empty  into  the  urethra  on  either  side  of  it. 

The  urethra  is  not  like  a  tube  of  unifonn  calibre,  but  is  a  canal 
of  varying  width  and  distensibility.  There  are  three  points  of 
physiological  narrowing : — 

I.  At  the  meatus. 

II.  Somewhere  in  the  third  inch. 

III.  The  membranous  urethra,  lying  between  the  anterior  and 
posterior  layers  of  the  triangular  ligament. 

The  points  of  widening  which  are  susceptible  of  instrumental 
dilatation  to  a  considerable  extent  are  as  follow:- — 

I.  The  fossa  navicularis,  which  is  located  Just  within  the  meatus, 
and  contains  in  its  roof  a  large  mucous  crypt:   the  lacuna  magna. 

II.  The  bulbous  urethra,  which  lies  just  in  front  of  the  tri- 
angular ligament  and  extends  for  one  and  one-half  inches.  It  is 
the  widest  and  most  dilatable  part  of  the  anterior  urethra. 

III.  The  prostatic  urethra,  usually  termed  the  posterior  urethra, 
is  capable  of  greater  distension  than  any  other  portion  of  the 
urethral  canal,  and  may  be  dilated  to  40  or  45  of  the  French  scale 
without  injury. 

The  mucous  membrane  which  lines  the  urethra  is  soft,  delicate, 
and  easily  lacerated,  and  is  composed  throughout  its  entire  length, 
excepting  the  fossa  navicularis,  of  epithelial  cells  of  the  cylindrical 
variety.     It  is  richly  supplied  with  glands  and  follicles. 

The  glands  of  Littre'  lie  beneath  the  mucous  membrane  in  the 
meshes  of  the  corpus  spongiosum  and  are  true  glands,  lined  with 
secreting  epithelium  and  provided  with  a  duct  which  empties  upon 
the  free  surface  of  the  urethral  mucous  membrane.  They  are  very 
numerous,  and  are  arranged  in  groups  together. 

The  follicles  of  Morgagni  are  simple  crypts  or  depressions  of 
the  urethral  mucous  membrane,  and  are  located  upon  the  roof  of 
the  canal. 


CHAPTER  III. 

ACUTE  URETHRITIS. 

Acute  urethritis  may  be  divided  into  three  varieties: — 

(a)  An  aseptic  catarrh,  in  which  no  micro-organisms  are  present 
and  which  is  due  entirely  to  chemical  irritation. 

(b)  Simple  urethritis,  which  is  occasioned  by  inoculation  of  the 
urethral  mucous  membrane  with  pyogenic  bacteria  (staphylococci  or 
streptococci). 

(c)  Specific  or  gonorrhoeal  urethritis,  which  is  produced  by  the 
gonococcus  of  Xeisser. 

Among  the  predisposing  causes  to  any  variety  of  urethral  inflam- 
mation may  be  mentioned  a  damaged  condition  of  the  urethra  from 
previous  disease  which  has  left  behind  granulations,  erosions,  or  a 
stricture;  anatomical  abnormalities,  such  as  a  long  and  narrow 
prepuce,  a  wide  urethral  orifice,  and  hypospadias;  certain  diathetic 
states,  such  as  gout,  rheumatism,  and  tuberculosis,  which  predispose 
to  inflammation  by  lowering  the  resisting  power  of  the  body  to 
bacterial  invasion. 


SIMPIE  URETHRITIS. 

Any  of  the  pus-producing  bacteria — i.e.,  staphylococcus,  strepto- 
coccus, etc. — will  excite  a  catarrhal  inflammation,  with  suppuration, 
of  the  mucous  membrane,  if  introduced  into  the  urethra.  The  micro- 
organisms may  be  introduced  from  without,  through  sexual  in- 
tercourse, and  are  contained  in  menstrual  discharges,  leucorrhcea, 
secretions  from  an  ulcerated  cervix,  and  utero-vaginal  discharges  of 
any  character.  They  may  also  be  introduced  upon  a  dirty  sound  or 
catheter.  On  the  other  hand,  the  bacteria  may  lie  dormant  and 
unsuspected  in  the  patient's  own  urethra,  concealed  in  the  crypts 
and  follicles  or  the  folds  of  mucous  membrane,  and  may  be  lighted 
into  activity  through  overindulgence  in  alcohol,  intense  erotic  excite- 
ment, excessive  coitus,  or  traumatism  produced  by  the  passage  of  a 
sound. 

(22) 


GONORRHCEA.  23 

The  inflammatory  process  in  a  simple  urethritis  is  less  severe 
than  in  the  gonorrhoeal  form,  and  it  is  limited  to  the  mucous  mem- 
brane, without  involving  the  submucous  tissues. 

TREATMENT. 
The  treatment  consists  in  hygienic  measures,  rendering  the 
urine  bland,  and  the  use  of  a  mild  astringent  injection  which  answers 
very  well  for  the  light  cases.  If  irrigations  are  used,  the  nitrate 
of  silver  (1  in  4000)  frequently  causes  a  prompt  subsidence  of  the 
discharge,  because  the  micro-organisms  do  not  penetrate  deeply  into 
the  tissues,  but  grow  on  the  surface  of  the  mucous  membrane.  Here 
the  irrigation  of  nitrate  of  silver  comes  in  direct  contact  with  them 
and  destroys  them,  and  at  the  same  time  causes  a  desquamation  of 
the  superficial  cells  upon  which  the  germs  have  proliferated.  One  or 
two  irrigations  may  succeed  in  ridding  the  tissues  of  micro-organisms 
and  infiltrated  epithelial  cells. 


GONORRHCEA. 

Gonorrhoeal  inflammation  of  the  urethra  is  caused  by  the 
gonococcus  of  Neisser.  The  period  of  incubation  is  usually  from  four 
to  seven  days,  but  in  rare  instances  may  extend  to  fourteen  days, 

PATHOLOGY. 

The  gonococci  are  introduced  into  the  urethra,  usually  in  utero- 
vaginal secretions  or  upon  an  infected  instrument.  They  do  not 
remain  upon  the  free  surface  of  the  urethral  mucous  membrane,  but 
rapidly  penetrate  between  the  epithelial  cells,  and  are  to  be  found 
in  the  submucous  connective  tissue  itself.  They  increase  and  multi- 
ply in  colonies,  in  the  interepithelial  spaces  and  upper  layers  of  the 
submucous  connective  tissue,  and  the  toxic  substances  which  they 
produce  cause  reaction  on  the  part  of  the  tissues,  which  is  character- 
ized by  dilatation  of  the  blood-vessels  and  discharge  of  serum  and 
leucocytes.  The  cylindrical  epithelium  cells  lining  the  urethra  are 
loosened  by  the  flow  of  secretion  and  are  desquamated,  forming 
erosions  of  the  epithelial  surface. 

An  active  process  of  phagocytosis  takes  place,  by  which  the 


34  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

gonococci  are  taken  into  the  pus-cells  and  thus  removed  from  the 
tissues,  and,  in  cases  which  run  a  normal  course,  the  gonococci  have 
almost  entirely  disappeared  from  the  submucous  connective  tissue 
and  deeper  layers  of  the  mucous  membrane  by  the  end  of  the  second 
or  third  week. 

When  the  stage  of  decline  commences,  the  epithelial  erosions 
begin  to  undergo  repair,  by  being  covered  with  squamous  epithelium 
in  many  layers.  The  gonococci  which  have  been  removed  from  the 
deeper  tissues  now  begin  to  grow  luxuriantly  on  the  free  surface  of 
the  mucous  membrane  after  the  manner  of  a  sod  of  grass,  and  a 
desquamation  of  the  upper  layer  of  the  newly-formed  epithelial  cells 
takes  place,  carrying  with  them  their  attached  colonies  of  gonococci. 

In  normal  and  ordinary  eases  the  process  of  getting  rid  of  the 


.^^^  aW^^ 


Fig.  4. — Goiiorrhoeal  Conjunctivitis.     Invasion   of  Epithelial  Layer  by 
Gonococci,  and  Desquamation  of  the  Superficial  Layers  of  Cells. 


gonococci  is  accomplished  in  the  ascending  stage  by  phagocytosis,  and 
in  the  stage  of  decline  through  desquamation  of  the  epithelial  cells;  so 
that  in  the  fifth  or  sixth  week,  in  favorable  cases,  the  gonococci  have 
disappeared  entirely  from  the  urethra,  and  the  inflammation  ceases. 
Morgagni's  crypts  and  Littre's  glands  are  also  alfected  by  the 
inflammatory  process,  which  occurs  within  their  cavities  as  well  as 
around  them,  and  the  cavities  of  the  glands  act  as  foci  of  suppuration 
and  incubating  places  for  gonococci  for  months  after  the  inflamma-" 
tion  has  ceased  on  the  free  surface  of  the  mucous  membrane.  An 
Infiltration  of  small  round  cells  which  are  derived  from  a  prolifera- 
tion of  the  fixed  connective-tissue  cells,  and  from  leucocytes  which 
have  escaped  from  the  capillaries,  occurs  as  part  of  the  process  of 
inflammation,  and  may  be  (a)  superficial,  or  confined  to  the  mucous 


GONORRHOEA.  25 

membrane  and  its  connective-tissue  layer  immediately  underneath, 
and  dipping  down  and  surrounding  Morgagni's  crypts  and  Littre's 
glands,  or  may  be  the  (b)  deep  form,  in  which,  in  addition  to 
affecting  the  mucous  membrane  and  glands,  the  small  round-celled 
infiltration  involves  the  deeper  submucous  tissues,  extending  into  the 
spongy  tissue  of  the  corpus  spongiosum,  in  severe  cases.  The  crypts 
and  follicles  are  usually  surrounded  by  and  imbedded  in  the  small 
round-celled  infiltration. 

Healing  of  the  lesions  is  brought  about  by  a  removal  from  the 
tissues  of  the  gonococci,  through  (a)  phagocytosis,  and  (h)  desquama- 
tion of  the  epithelial  cells,  which  have  been  invaded  by  the  gonococci. 
When  the  gonococci  have  been  entirely  removed  suppuration  ceases. 

The  erosions  either  (a)  become  covered  with  squamous  epi- 
thelium in  many  layers,  which  ofiiers  a  barrier  to  the  renewed  inva- 
sion of  the  tissues  by  gonococci,  or  (b)  the  erosions  remain  without 
being  covered  by  squamous  epithelium,  but  become  the'  seat  of 
granulations,  and  occasion  a  gleety  discharge. 

The  small  round-celled  infiltration  (a)  disappears  by  absorption, 
especially  when  superficial  and  confined  to  the  mucous  membrane, 
and  the  urethra  becomes  healthy,  soft,  and  flexible,  or  (b)  the  small 
round-celled  infiltration  is  not  absorbed,  especially  when  deep  seated, 
— i.e.,  involving  submucous  tissue  and  cavernous  tissue  of  the  corpus 
spongiosum, — but  becomes  transformed  into  tj-tie  fibrous  connective 
tissue,  called  stricture. 

Relapses  are  frequent,  and  are  due  to  reinfection  of  the  sub- 
mucous tissues  from  a  focus  of  suppuration  located  either  in  (a) 
Morgagni's  crypts  or  Littre's  glands,  (b)  the  seminal  vesicles,  or  (c) 
Cowper's  glands  or  the  prostatic  crypts. 

The  manner  in  which  a  relapse  takes  place  is  as  follows:  If 
premature  coitus  or  an  excess  of  beer  is  indulged  in,  hyperemia  of 
the  mucous  membrane,  with  increased  secretion,  follows  and  the  pro- 
tecting layer  of  squamous  epithelium  is  torn  asunder.  The  gono- 
cocci penetrate  through  these  clefts  into  the  deeper  tissues  and  again 
cause  their  irritative  symptoms. 

If  the  gonococci  remain  in  the  urethra  for  a  considerable  length 
of  time  a  state  of  tolerance  of  the  tissues  is  established  and  with 
each  successive  relapse  the  inflammatory  reaction  becomes  less  and 
less  until,  with  the  third  or  foijrth  relapse,  the  energy  of  reaction 
is  not  enough  to  bring  the  gonococci  out  of  the  submucous  tissues. 
As  a  consequence,  the  gonococci  remain  and  give  rise  to  a  perma- 


26  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

nent  irritation  of  the  submucous  connective  tissue,  an  infiltration  of 
snuili  round  cells  occurs,  and  the  gonorrhoea  becomes  chronic. 


COURSE. 

The  inflammation  begins  at  the  meatus,  and  in  favorable  cases 
affects  the  anterior  urethra  only,  stopping  at  the  cut-off  muscle. 

Stages. — Prodromal. — The  symptoms  are  a  slight  tickling  at  the 
meatus,  and  a  light-bluish  sticky  discharge  with  some  slight  stinging 
on  urination.  These  last  a  couple  of  days,  and  then  begins  the 
increasing  stage:  The  amount  of  pus  increases.  It  is  creamy  yellow 
in  color  or  greenish  yellow  from  admixture  with  blood.  Htemor- 
rhages  may  occur.  The  pain  on  urination  is  intense,  and  is  occa- 
sioned by  the  sudden  distension  of  the  infiltrated  walls  of  the  urethra 
by  the  outflow  of  urine.  Neuralgic  pains  in  the  back,  perineum, 
groin,  and  spermatic  cord  are  present.  Constitutional  disturbance 
in  the  shape  of  fever  and  a  feeling  of  prostration  often  occurs.  The 
prepuce  may  become  oedematous  and  cause  phimosis  or  paraphimosis. 

Chordee  is  of  frequent  occurrence.  It  consists  in  an  erection 
of  the  penis,  with  a  painful  incurvation  downward.  It  is  caused 
by  an  infiltration  into  the  spongy  tissue  of  the  corpus  spongiosum 
which  surrounds  the  urethra  and  renders  it  rigid  and  inextensible. 
On  account  of  the  rigidity  of  the  urethra  the  stream  becomes  small 
and  twisted,  and  dribbling  after  urination  occurs. 

This  condition  continues  without  change  for  the  better  for 
about  three  weeks,  and  during  this  time  it  is  known  that  the  gono- 
cocei  have  been  proliferating  in  the  submucous  tissues.  At  the 
moment  when  the  gonococci  have  been  removed  from  the  deep 
tissues  and  begin  to  grow  upon  the  free  surface  of  the  mucous  mem- 
brane, the  acute  symptoms  subside,  and  usually  in  the  course  of  the 
third  week  the  stage  of  decline  begins.  The  pain  on  urination  and 
the  chordee  lessen,  the  discharge  becomes  more  watery  and  less  in 
quantity,  until  it  finally  diminishes  to  a  drop  in  the  morning,  which 
ultimately  disappears. 

Endoscopic  examination,  or  the  introduction  of  any  instrument, 
should  be  strictly  avoided  in  the  acute  stage.  But  if  an  endoscope 
were  used,  the  appearances  would  be  as  follows: — 

The  mucous  membrane  appears  swollen,  a;dematous,  intensely 
red,  and  covered  with  pus.  The  glands  and  follicles  are  very 
markedly  affected.     The  mucous  membrane  around  their  openings 


GONORRHCEA,  27 

is  more  swollen  and  the  openings  themselves  gape.  Erosions,  from 
desquamation  of  the  cylindrical  epithelium,  appear  in  the  vicinity  of 
the  glands.  Granulations  may  form  upon  the  erosions,  later  in  the 
course  of  the  disease.  The  submucous  tissue  is  infiltrated,  rendering 
the  canal  swollen  and  rigid. 

Examination  of  Urine. — The  two-glass  urine  test  should  be 
made  at  each  visit  to  determine: — 

(a)  If  the  posterior  urethra  has  been  affected. 

(b)  The  amount  of  pus  secreted. 

The  urine  passed  into  a  glass  appears  turbid  from  admixture 
with  pus,  and  little  clumps  or  masses  of  desquamated  epithelium 
are  present.  After  standing,  the  pus  settles  to  the  bottom  of  the 
glass,  and  a  cloud  of  mucus  appears  floating  above  it.  As  the  case 
goes  on  toward  recovery  the  pus  disappears,  but  the  hypersecretion 
of  mucus  continues,  and  occasions  a  cloudy  appearance  in  the  urine, 
resembling  mucilage  added  to  it. 

After  the  mucus  disappears  dap-shreds  persist  for  months,  show- 
ing that  isolated  portions  of  mucous  membrane  are  not  covered  with 
epithelium,  and  are  still  secreting  pus. 


Fig.  5. — Gononhoeal  Pus. 

Microscopic    Examination    of    Pus.  —  In    the    ascending    stage 
numbers  of  pus-cells  are  present  containing  gonococci  within  the 


28  DISEASES  or  THE  URETHRA  AND  ITS  ADNEXA. 

cell.  In  the  stage  of  decline  a  diminution  is  noted  in  the  number  of 
pus-cells,  fewer  gonococci  are  present,  and  squamous  epithelial  cells 
make  their  appearance.  Finally  the  pus-cells  and  gonococci  disap- 
pear, and  squamous  epithelium  alone  is  found. 

It  is  of  the  utmost  importance  to  make  sure  of  the  entire  dis- 
appearance of  all  gonococci  before  permitting  coitus,  on  account  of 
the  danger  of  infection,  in  case  the  gonococci  are  not  removed. 

If  no  purulent  discharge  is  obtainable  from  the  meatus  it  is 
proper  to  excite  a  simple  urethritis,  by  injecting  the  urethra  with 
nitrate-of-silver  solution  gr.  x  to  the  ounce. 

If  gonococci  are  lurking  in  the  crypts  or  a  granular  patch,  the 
suppuration  caused  by  the  injection  will  bring  them  to  the  surface, 
and  they  can  be  found  by  microscopic  examination  of  the  discharge. 


1% 


Fior.  6. — Gonococci  Growing  in  Clusters. 


MORPHOLOGY    OF    THE    GONOCOCCUS. 

The  gonococcus  resembles  in  appearance  two  coffee-beans  placed 
side  to  side,  and,  as  it  is  removed  by  phagocytosis  from  the  tissues, 
will  of  necessity  be  found  lying  within  the  pus-cells.  A  few  gonococci 
may  be  found  outside  the  pus-cells,  if  these  have  been  ruptured.  In 
the  descending  stage  of  gonorrhoea  the  gonococci  are  found  adherent 
to  and  growing  upon  the  desquamated  squamous  epithelial  cells. 

Other  micro-organisms — for  example,  the  pseudo-gonococcus — 
which  are  not  pathogenic  resemble  the  gonococcus  in  shape,  but  it 
is  believed  to-day  that  the  gonococci  can  always  be  recognized  by 
decolorizing  them  by  Gram's  solution. 

The  microscopic  examination  for  the  gonococcus  is  pursued 
as  follows  in  the  Hoagland  Laboratory,  after  the  method  of  A. 
Hymans  Van  den  Bergh: — 

I.  Make  a  thin  smear  on  a  cover-glass  of  the  pas  supposed  to 
contain  the  micro-organisms. 

II.  Dry  in  the  air  and  then  fix  over  a  flame. 


GONORRHCEA.  29 

III.  Stain  in  Loffler  solution  of  methylene-blue  (prepared  by 
Eimer  &  Amend)  for  V,  to  1  minute. 

TV.  Wash  in  water,  dry,  mount  in  balsam,  and  examine. 

The  gonococcus  is  found  on  examination  to  be  stained  blue.  In 
order  to  differentiate  the  gonococcus  from  the  pseudo-gonococcus  or 
other  similar  organisms,  Gram's  method  of  decolorization  may  be 
used,  and  if,  after  using  it,  the  micro-organisms  are  found  to  have 
lost  their  blue  color  and  become  colorless,  the  diagnosis  of  gono- 
coccus is  established. 

If,  on  the  other  hand,  the  micro-organisms  still  retain  the  blue 
color,  it  is  a  proof  that  they  are  not  gonococci. 

Gram  Method. — I.  Stain  in  aniline-water  gentian-violet  for  one 
minute. 

II.  Pour  off  stain  and  wash  or  blot  gently. 

III.  Place  in  Gram's  solution  1  minute. 

IV.  Decolorize  in  absolute  alcohol  2  ^/o  to  3  minutes. 

V.  Dry  and  mount  in  balsam. 

VI.  Examine. 

The  gonococcus  is  found  to  be  decolorized,  but  other  micro- 
organisms retain  the  blue  color. 

Formulae. — To  make  aniline-water  shake  up  5  cubic  centimetres 
of  aniline-oil  in  100  cubic  centimetres  of  plain  water.  Shake 
violently,  and  filter  through  a  wet  filter. 

Gentian-violet. — To  1  cubic  centimetre  of  saturated  alcoholic 
solution  of  gentian-violet  add  20  cubic  centimetres  of  aniline-water. 

These  added  together  make  aniline-water  gentian-violet,  which 
does  not  keep,  as  a  mixture,  more  than  a  week. 

Gram's  Solution. — Iodine  crystals,  1  gramme;  potassium  iodide, 
2  grammes;   water,  300  cubic  centimetres. 

DURATION  OF  AN  ATTACK  OF  GONORRHCEA. 

When  the  posterior  urethra  is  not  affected  a  favorable  case  of 
gonorrhoea  recovers  in  six  to  eight  weeks.  In  very  exceptional 
instances  recovery  may  occur  in  three  to  four  weeks,  but  in  these 
cases  there  is  always  a  doubt  as  to  the  correctness  of  the  diagnosis 
of  true  specific  gonorrhoea. 

The  first  attack  is  the  most  severe,  but  most  liable  to  recover 
without  stricture.  Later  attacks  are  apt  to  follow  the  course  of 
the  first  one,  in  having  a  repetition  of  the  complications. 


30 


etc. 


DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

The  causes  which  retard  recovery  may  be  grouped  as  follows:^ 

(a)  Complications,  posterior  urethritis,  prostatitis,  etc. 

(6)  Reinfection  from  a  urethral  gland,  seminal  vesicle,  prostate, 

(c)  Lack  of  rest. 

(d)  Habits  of  drinking. 

(e)  Injections  which  are  too  strong  or  too  frequently  repeated. 

(f)  Constitutional  causes:    i.e.,  gout,  tuberculosis,  etc. 

(g)  Premature  coitus. 

TREATMENT. 

Gonorrhoea  is  a  self-limited  disease,  and  the  suppuration  may  be 
looked  upon  as  an  effort  on  the  part  of  the  tissues  to  remove  the 
invading  micro-organisms;  so  that  when  the  last  gonococcus  is  re- 
moved suppuration  ceases. 

An  expectant  plan  of  treatment  can  only  be  carried  out  excep- 
tionally, as  in  military  hospitals,  for  instance.  Here  it  is  found  that 
if  a  patient  with  gonorrhoea  is  put  to  bed  and  fed  on  a  bland  diet, 
consisting  chiefly  of  milk,  in  forty-five  days,  on  an  average,  the 
gonococci  are  eliminated  from  the  tissues  and  the  suppuration  has 
ceased.  Under  the  existing  social  and  business  conditions,  however, 
such  a  plan  of  treatment  is  practically  impossible,  and  we  have  to 
adopt  the  methodic  treatment. 

As  the  gonorrhoeal  inflammation  begins  at  the  meatus  and  does 
not  reach  the  posterior  urethra  until  the  third  week,  or  in  favorable 
cases  not  at  all,  we  will  first  consider  the  treatment  of  inflammation 
which  is  limited  to  the  anterior  urethra,  and  take  up  posterior 
urethritis  in  a  subsequent  section. 

ANTERIOR  URETHRITIS. 

Methodic  Treatment. — -There  are  certain  hygienic  directions 
which  the  patient  should  observe:  he  should  keep  quiet  and  spend 
as  much  time  lying  on  a  sofa  or  bed  as  possible,  and  should,  of 
course,  avoid  all  sources  of  sexual  or  erotic  excitement.  He  should 
be  warned  of  the  danger  of  gonorrhoeal  ophthalmia,  and  directed  to 
wash  his  hands  after  handling  the  penis  or  dressings,  to  avoid  carry- 
ing any  pus  into  the  eyes. 

The  diet  should  be  non-stimulating,  and  the  patient  should 
avoid  meat  in  excess,  highly  seasoned  or  salty  foods,  sauces,  condi- 
ments, strong  tea  or  coffee,  pickles,  tomatoes,  asparagus,  and  alco- 


.      .ft'  'l. 


f.. 


.-:.->i 


r-^>^ 


'^^ 


v-^^] 


I.  Section  of  Chancroid. 

a,  Small  round-celled  infiltration. 
6,  Lymphatics,  open  and  gaping. 
C,   Blood-vessel. 


n.  Acute  Gonorrhoea.  • 

a.  Cylindrical  epithelium,  infiltrated  with  pus-cells  and  gonococcl. 
6,  Submucous  connective  tissue,  with  pus-cells  and  gonococci. 


(From  ••  Die  Syphilis  uiid  die  VeiierisclieD  Kraukheiten,"  von  Dr.  Eruest  Fiuger.) 


GONORRHCEA.  31 

holic  drinks  of  all  kinds,  of  which  beer  and  champagne  are  especially 
detrimental. 

Dressing's  for  the  purpose  of  catching  the  discharge  and  keeping 
it  from  the  clothing  are  always  necessary.  The  best  form  is  made 
by  cutting  off  the  foot  of  a  stocking  and  placing  some  absorbent 
cotton  at  the  bottom;  the  penis  is  placed  within  it  and  the  bag  sus- 
pended from  a  waist-band. 

Constricting  the  penis  by  wrappings  should  be  carefully  avoided, 
so  as  not  to  interfere  with  the  return-circulation.  If  the  discharge  is 
but  trifling,  a  pledget  of  cotton  may  be  placed  under  a  long  fore- 
skin to  absorb  it;  but  the  cotton  is  not  to  be  recommended  if  the 
discharge  is  profuse,  as  it  will  prevent  the  pus  from  flowing  out 
freely  from  the  meatus,  and  cause  it  to  dam  back. 

A  suspensory  bandage  should  be  worn  in  every  case  to  relieve  the 
sensation  of  dragging  on  the  spermatic  cord  and  perhaps  lessen  the 
danger  of  epididymitis. 

Therapeutic  Treatment. — The  balsams  of  copaiba,  cubebs,  and 
sandal-wood  oil  have  had  for  years  a  well-deserved  reputation  as  anti- 
blennorrhagics.  They  are  eliminated  by  the  kidneys,  and  affect  the 
inflamed  urethra  as  they  pass  over  it,  held  in  solution  in  the  urine. 

Sandal-wood  oil  is  best  adapted  to  the  increasing  stage,  but  acts 
well  throughout  the  whole  course  of  the  disease.  The  balsams  of 
copaiba  and  cubebs  have  fallen  largely  into  disuse,  but  are  sometimes 
serviceable  in  the  descending  stage  of  a  gonorrhoea. 

The  dose  of  sandal-wood  oil  and  the  balsams  is  from  15  to  20 
drops  in  capsules,  three  times  a  day. 

Sandal-wood  oil  sometimes  causes  an  intense  pain  in  the  back, 
or  disagrees  with  the  digestion,  and  has  to  be  abandoned  on  these 
accounts,  while  copaiba  often  causes  an  erythematous  eruption  re- 
sembling measles. 

While  sandal-wood  oil  and  the  balsams  are  a  useful  adjuvant 
in  gonorrhoea,  it  is  necessary  to  have  recourse  to  other  measures  to 
efl^ect  a  cure. 

Treatment  of  the  Increasing  Stage. — The  bowels  should  be 
regulated  by  a  saline  cathartic  given  every  second  morning  before 
breakfast,  which  depletes  the  pelvic  blood-vessels  and  lessens  con- 
gestion. 

All-alies  or  an  alkaline  mineral  water  should  not  be  prescribed 
as  a  routine  measure,  for  an  alkaline  reaction  of  the  patient's  urine 


32  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

is  always  caused  by  his  abstinence  from  meat  and  his  free  use  of 
milk,  and  the  best  prophylactic  against  the  development  of  cystitis 
in  gonorrhoea  is  a  strongly  acid  reaHion  of  the  urine,  which  inhibits 
the  growth  of  any  bacteria  which  may  find  their  way  into  the  bladder. 

Diluents. — The  patient  should  be  directed  to  drink  considerable 
quantities  of  pure  distilled  water — a  glass  every  hour  or  two,  with 
the  object  of  ivashvng  out  the  urinary  passages  and  keeping  the 
urethra  free  from  secretions  which  would  otherwise  form  excellent 
culture-media  for  gonococci. 

Sandal-wood  oil  is  administered  by  the  mouth,  preferably  in 
capsules.  The  well-known  Lafayette  mixture  is  commonly  used  in 
hospital  and  dispensary  practice,  but  it  has  the  disadvantages  of  con- 
taining an  alkali  and  of  having  an  abominable  taste.  Its  formula  is 
as  follows: — 

B  Extract!  hyoscyamus  fluidi f3s3. 

Potassii   citratis -. 3j- 

Olei  santali  flavi f^ss. 

Aquae  destillatae fSij- 

Syrupi  acacise q.  s.  ad  f^vj. 

Olei  gaultheriae  f 3ss. 

M.     Sig. :    Two  teaspoonfuls  at  a  dose. 

The  hurning  on  urination  is  lessened  in  some  degree  by  the 
sandal-wood  oil,  but  if  very  severe  can  be  relieved  by  injecting  3ss 
of  4-per-cent.  cocaine  solution  into  the  urethra. 

The  local  treatment  by  means  of  astringent  injections  is  entirely 
contra-indicated  during  the  ascending  stage,  for,  as  we  have  already 
noted  in  considering  the  pathology,  the  gonococci  at  this  time  are 
in  the  upper  layers  of  the  submucous  connective  tissue  and  the 
deeper  cells  of  the  mucous  membrane,  and  they  are  being  removed 
from  the  deeper  tissues  as  rapidly  as  possible  by  the  phagocytic 
action  of  the  leucocytes.  Under  these  conditions  the  action  of  an 
astringent  is  to  hinder  the  elimination  of  the  gonococci  from  the 
depths,  and  so  retard  the  natural  healing  process. 

A  pure  antiseptic,  however, — such  as  some  of  the  new  silver 
salts  or  irrigations  of  permanganate  of  potash  by  the  Janet  method, 
— is  entirely  in  order,  and  is  effectual  in  moderating  the  severity 
and  shortening  the  duration  of  the  disease. 

Treatment  of  the  Stage  of  Decline. — In  the  third  week  the 
ascending  stage  has  usually  passed  its  acme,  the  chordee  lessens,  and 


GONORRHCEA.  33 

the  pain  on  urination  is  diminished.  The  character  of  the  discharge 
also  changes.  It  is  no  longer  thick  yellow  or  greenish  pus,  but  is 
thinner,  contains  more  mucus,  and  is  whiter  and  more  watery  in 
color.  When  these  conditions  occur,  the  administration  of  sandal- 
wood oil  can  be  stopped  and  balsam  copaiba,  or  oleoresin  of  cubebs 
substituted. 

The  use  of  astringent  injections  should  be  strictly  avoided  until 
the  stage  of  decline,  for  the  reason  that,  as  stated  before,  in  the 
ascending  stage  the  gonococci  are  in  the  deeper  layers  of  the  mu- 
cous membrane  and  subepithelial  tissues,  and  they  cannot  be  de- 
stroyed, at  this  time,  by  the  use  of  astringents,  which  also  act  as 
chemical  irritants  and  interfere  with  phagocytosis. 

The  improvement  in  the  symptoms  of  the  patient  is  caused  by 
the  fact  that  in  the  stage  of  decline  the  gonococci  have  been  elimi- 
nated from  the  deep  tissues  and  are  now  growing  on  the  free  surface 
of  the  mucous  membrane  of  the  virethra,  and  the  erosions  are  being 
healed  by  the  formation  of  squamous  epithelium.. 

These  facts  can  be  demonstrated  by  finding,  with  the  micro- 
scope, colonies  of  gonococci  growing  on  desquamated  cells  of  epi- 
thelium, which  are  contained  in  the  discharge. 

Under  these  conditions  a  combination  of  an  astringent  and  an 
antiseptic  as  an  injection  is  called  for,  in  order  to  destroy  the  gono- 
cocci, heal  the  erosions,  and  contract  the  dilated  blood-vessels. 

Syringes  are  of  various  shapes  and  made  of  soft  rubber,  hard 
rubber,  and  glass.  An  important  point  to  observe  is  that  the  nozzle 
is  not  prolonged  into  a  snout,  which  would  irritate  the  mucous  mem- 
brane of  the  fossa  navicularis.  In  addition,  it  is  essential  that  the 
syringe  should  hold  from  three  to  four  drachms  of  fluid,  so  that  when 
the  injection  is  given  the  folds  of  the  urethra  may  be  fully  distended. 

Technique  of  Injecting. — The  patient  urinates  to  cleanse  the 
urethra,  and  then,  holding  the  penis  in  the  left  hand,  draws  it  out, 
vhile  with  the  right  hand  the  injection  is  slowly  forced  from  the 
syringe  into  the  urethra  and  held  for  two  to  five  minutes.  It  is 
not  necessary  to  make  pressure  on  the  perineum  to  keep  the  fluid 
from  entering  the  bladder,  as  the  fluid  is  kept  from  flowing  back- 
ward by  the  tonic  contraction  of  the  cut-off  muscle. 

Formulse  for  Astringent  Injections. — 

IJ  Zinci    sulphatis gr.  i-v. 

Aqua3 fSj- 


34  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

R   Zinci   jieiiuanganatis S^-  h 

Aquae fSviij. 

B  Argenti   nitratis gr-  J- 

Aquae f3j- 

B  Zinci   sulphatis gr.  xv. 

Plunibi   acetatis gr.  xxx. 

Aquae  destillatae q.  s.  ad  fgvj. 

M.     Sig.:     Insoluble.     Hold  in  urethra  and  let  out  drop  by  drop. 

R  Extract!  Hydrastis  fluidi    (non-alcoholic) f3ss-j. 

Aquae fSj- 

M.  Sig.:  For  mucopurulent  discharge  where  simple  astringent  is  in- 
dicated. 

Ultzmann's  Injection. — 

R  Zinci   sulphatis gr.  iv-xij. 

Pulvis    aluminis gr.  iv-xij. 

Acidi  carbolici gr.  iv. 

Aquae f Siv. 

The  above  is  particularly  useful  in  the  stage  of  decline  where 
discharge  fails  to  diminish  under  other  applications. 

R  Bismuthi  subnitratis gr.  xl. 

Mucilaginis  acaciae   5j- 

Aquae q.  s.  ad  f^iv. 

M.  Sig.:  Shake  well.  Use  once  a  day  at  bed-time  and  hold  in  urethra 
five  minutes. 

The  Use  of  Injections. — An  astringent  injection  should  never 
be  used  in  the  presence  of  posterior  urethritis  nor  in  the  ascending 
stage  of  a  gonorrhoea,  for  until  the  stage  of  decline  sets  in  the  gono- 
eocci  lie  deep  within  the  tissues  and  entirely  out  of  reach  of  astrin- 
gents applied  to  the  surface  of  the  mucous  membrane.  In  addition 
to  being  of  no  value  in  destroying  the  gonococci,  astringents  are 
actually  harmful  from  the  irritation  of  the  tissues  which  their  use 
entails. 

In  the  stage  of  decline,  however,  when  the  burning  on  urination 
is  decreased  and  the  discharge  has  become  thin  and  watery,  the 
gonococci  are  growing  upon  the  free  surface  of  the  mucous  mem- 
brane and  can  be  destroyed  by  the  application  of  the  various  injec- 
tions which  combine  an  antiseptic  and  astringent.    At  the  same  time 


GONORRHCEA.  35 

the  dilated  blood-vessels  are  contracted  by  the  astringent  and  the 
inflammation,  through  their  agency,  is  lessened. 

An  injection  should  never  cause  more  than  a  slight  burning. 
After  a  time  the  urethra  becomes  tolerant  of  one  form  of  injection, 
and  it  is  necessary  to  increase  its  strength  or  to  change  the  formula. 

The  prolonged  use  of  an  injection  may  in  itself  induce  an  irri- 
tation of  the  mucous  membrane  of  the  urethra,  which  is  evidenced 
by  shreds  in  the  urine,  and  the  formation  of  a  slight  amount  of 
secretion,  which  causes  the  lips  of  the  meatus  to  stick  together. 

In  order  to  determine  if  the  treatment  is  responsible  for  keep- 
ing up  the  discharge,  it  is  desirable  to  stop  the  use  of  the  injection 
for  forty-eight  hours,  to  see  if  the  last  traces  of  inflammation  will 
not  disappear  spontaneously. 

If  at  the  end  of  this  time  the  discharge  still  persists  in  small 
quantity  and  on  microscopic  examination  the  shreds  are  found  to 
be  made  up  of  squamous  epithelium  and  contain  no  gonococci,  an 
injection  of  bismuth  used  at  night,  which  acts  mechanically  by  coat- 
ing over  the  mucous  membrane,  frequently  causes  a  cessation  of  the 
catarrh  in  six  or  eight  days. 

The  patient,  however,  cannot  be  considered  cured  imtil  he  has 
resumed  his  ordinary  way  of  life  for  some  days  and  remained  free 
from  a  relapse,  because  a  few  gonococci  may  have  lain  unsuspected 
in  a  crypt  or  follicle  and  on  slight  provocation  come  to  the  surface 
and  cause  a  reinfection. 

The  dbortive  treatment  of  gonorrhcBa,  by  means  of  strong  solu- 
tions of  nitrate  of  silver,  injected  into  the  urethra  or  applied  through 
an  endoscope,  is  not  to  be  recommended.  The  micro-organisms  lie 
deep  in  the  tissues,  and  cannot  be  reached  by  applications  made  upon 
the  surface  of  the  mucous  membrane,  and  an  increased  irritation  of 
the  tissues  is  sure  to  follow,  without  any  shortening  of  the  course 
of  the  disease. 

Irrigations  with  Permanganate  of  Potash:  Janet's  Method. — In 
the  last  few  years  the  treatment  of  gonorrhoea,  suggested  by  Janet, 
of  Paris,  by  means  of  irrigations  of  permanganate-of-potash  solu- 
tion, has  been  extensively  used.  Its  adherents  are  enthusiastic  in 
praise  of  its  merits,  Goldberg,  of  Cologne,  citing  statistics  showing 
that  90  per  cent,  of  the  cases  of  gonorrhoea  were  cured  in  fourteen 
days  by  this  means. 

The  permanganate  irrigation  is  a  valuable  method  of  treating 
gonorrhoea^  but  these  claims  as  to  its  advantages  would  seem  to  be 


5G 


DISEASES  OF  THE  URETHRA  AND  ITS  ADXEXA. 


extravagant.  According  to  the  experience  of  other  men  who  use  this 
form  of  treatment,  it  is  impossible  to  attain  any  such  results,  and 
many  specialists  have  given  up  the  method  in  disgust,  after  a  fair 
trial. 


Fig.  7. — Valentine's  Iniijator, 


From  the  author's  reading  and  experience  with  the  Janet 
method,  the  following  would  seem  to  be  a  fair  estimate  of  its  value:— 

The  profuse  purulent  discharge  is  checked,  in  most  cases,  in 
about  eight  days;  but  even  under  treatment  relapses,  accompanied 
by  a  free  discharge  of  pus,  occur  m  nearly  every  case,  without 
apparent    cause,    and    often    several    times.      These    relapses    yield 


GONORRHCEA.  37 

promptly  to  irrigations  of  permanganate,  but  the  convalescence  is 
retarded,  and  the  irrigations  have  to  be  continued  daily  to  hold  the 
pus  in  check  and  to  control  the  thin,  serous  discharge  which  lasts 
after  suppuration  ceases.  The  course  of  the  case  is  in  this  way 
dragged  out;  so  that  at  least  one  month,  and  very  often  two  months 
or  more,  are  required  to  effect  a  cure. 

The  advantages  of  the  method  are  that  posterior  urethritis  is  of 
exceptional  occurrence.  The  discharge  from  the  meatus  is  so  slight 
as  not  to  cause  any  inconvenience,  and  there  is  no  burning  on  urina- 
tion and  no  chordee. 

The  disadvantages  of  the  Janet  method  are  the  expense,  trouble, 
and  inconvenience  entailed  upon  the  patient  by  being  obliged  to  re- 
port at  his  physician's  office  once  or  twice  a  day  for  treatment. 

The  objection  which  has  been  raised,  that  the  frequent  irriga- 
tion of  the  bladder  or  the  relaxation  of  the  cut-off  muscle  will  in 
time  do  harm,  is,  I  believe,  entirely  unfounded. 

In  order  to  cut  short  the  course  of  the  gonorrhoea  by  Janet's 
method  it  is  necessary  to  begin  treatment  earhj  in  the  ascending 
stage. 

Technique. — The  patient  sits  easily,  well  forward  on  a  chair,  and 
rests  his  back  against  the  back  of  the  chair.  The  irrigator  nozzle 
is  inserted  into  the  meatus  and  the  anterior  urethra  washed  out. 
If  it  is  desired  that  the  fluid  should  enter  the  bladder,  the  irri- 
gator is  elevated  to  the  height  of  nine  feet  from  the  floor.  The  pa- 
tient is  instructed  to  take  a  long  breath  and  attempt  to  urinate.  As 
soon  as  the  cut-off  muscle  is  relaxed  the  solution  from  the  irrigator 
flows  into  the  bladder,  and  when  the  bladder  is  filled  the  patient 
stands  up  and  urinates,  and  the  solution  flows  out  through  the 
urethra. 

The  urethra  is  irrigated  twice  a  day  for  the  first  week,  and  then 
once  a  day  till  the  patient  is  cured.  The  first  irrigation  is  used  of 
a  strength  of  1  to  1000  for  its  abortive  effect,  in  the  anterior  urethra 
alone,  and  the  second  time  of  a  strength  of  1  to  6000.  From  this 
time  on  the  strength  of  the  solution  should  be  1  to  3000. 

As  a  rule,  the  first  irrigation  diminishes  the  secretion  materially, 
and  when  after  a  few  days  the  secretion  is  scanty  in  amount  and 
thin  the  irrigation  is  allowed  to  flow  through  the  posterior  urethra 
into  the  bladder. 

After  the  first  week  one  irrigation  a  day  is  sufficient,  and  the 


38  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

strength  may  be  increased  to  1  in  1500,  unless  it  causes  tenesmus  and 
bladder  irritation. 

The  effect  of  permanganate  irrigations  is  to  cause  energetic  dis- 
infection of  the  mucous  membrane  by  removing  and  mechanically 
washing  away  accumulated  secretions,  as  is  the  case  with  the  irriga- 
tion of  any  suppurating  wound-cavity.  The  permanganate  also 
causes  an  oedematous  swelling  of  the  epithelial  cells,  which  inhibits 
the  growth  of  colonies-  of  bacteria. 

It  has  been  suggested  recently  that,  after  the  discharge  is  re- 
duced, at  the  end  of  the  first  week,  the  destruction  of  gonocodci  may 
be  hastened  by  allowing  the  patient  to  use  Protargol  or  Largin  as  an 
injection,  and  when  the  case  has  progressed  so  far  that  there  is  no 
more  pus-formation,  but  only  a  slight  serous  discharge  and  shreds  in 
the  urine,  an  astringent  injection  may  complete  the  cure. 

The  Salts  of  Silver. — In  the  last  couple  of  years  various  combina- 
tions of  silver  with  an  albuminoid  base,  such  as  Protargol,  Largin, 
Argonin,  and  Argentamin,  have  been  introduced  for  the  treatment 
of  gonorrhoea. 

According  to  Finger,^  Protargol  and  Largin  may  be  regarded  as 
pure  antiseptics  without  astringent  properties  and  entirely  unirri- 
tating  to  the  tissues;  so  that  they  can  be  used  in  the  ascending  stage. 
They  are  in  the  form  of  a  soluble  albuminate  of  silver,  which  does 
not  coagulate  the  tissues,  and  has  the  power  to  penetrate  deeply  and 
destroy  the  gonococci  which  lie  under  the  mucous  membrane. 

The  action  of  the  silver  salts  is  incomplete,  and  they  do  not 
destroy  all  the  gonococci,  particularly  those  in  the  mucous  crypts 
and  follicles;  so  that  if  their  use  is  discontinued  too  soon  a  relapse 
is  liable  to  occur. 

It  has  been  found  experimentally  that  Protargol  and  Largin  must 
remain  in  contact  with  the  tissues  for  10  minutes,  in  order  to  exert 
their  destructive  action  upon  the  gonococci.  A  shorter  time  is  in- 
sufficient, and  fails. 

Another  advantage  possessed  by  Protargol  and  Largin  is  that,  in 
cases  where  the  inflammation  has  passed  beyond  the  cut-off  muscle 
and  attacked  the  posterior  urethra,  on  holding  a  solution  of  either 
drug  in  the  urethra  for  a  short  time  the  cut-off  muscle  relaxes,  on 
account  of  the  mild  and  unirritating  character  of  the  remedies,  and 


'  Wiener  Klinik,  January,  1900. 


GONORRHCEA.  39 

allows  the  solution  to  flow  back  and  come  in  contact  with  the  poste- 
rior urethra  and  exercise  its  bactericidal  power. 

If  a  strong  and  irritating  solution,  like  nitrate  of  silver,  is 
injected  into  the  anterior  urethra,  a  xeflex  contraction  of  the  cut-off 
muscle  is  always  caused. 

In  the  ascending  stage  of  gonorrhoea  Protargol  and  Largin  are 
the  most  useful  of  the  silver  salts;  but  in  the  stage  of  decline  the 
gonococci  are  no  longer  in  the  deep  tissues,  but  superficially  seated. 
The  indication  at  this  time  is  to  destroy  them  on  the  surface  of  the 
mucous  membrane  and  at  the  same  time  exert  an  astringent  effect 
upon  the  dilated  vessels.  Argonin  and  Argentamin  are  astringents 
in  addition  to  being  germicides,  and  are  indicated  in  this  stage. 

Method  of  Using. — The  use  of  Protargol  solution  (V4  to  1  per 
cent.)  should  be  begun  at  once  in  the  ascending  stage,  and  the  patient 
should  be  instructed  to  make  the  injections  eight  hours  apart.  This 
is  said  to  be  an  important  point.  Before  using  the  injection  he 
should  urinate,  and,  as  urine  decomposes  the  silver  solutions,  he 
should  wash  out  the  urethra  with  3  or  3  syringefuls  of  warm  water. 
The  injection  should  be  warmed  before  using,  the  syringe  should 
contain  3  to  4  drachms  in  order  to  distend  the  folds  of  the  urethra, 
and  the  solution  should  be  retained  in  the  urethra  from  ten  to 
fifteen  minutes. 

In  the  course  of  a  few  days  the  acute  symptoms  subside  and 
the  pain  on  urination  and  chordee  disappear.  It  should  be  noted 
that,  if  treatment  be  discontinued  at  this  point,  even  though  the  dis- 
charge has  ceased  and  only  a  few  shreds  remain  in  the  urine,  a 
relapse  is  certain  to  occur  in  from  two  to  three  weeks,  for  a  few 
gonococci  have  been  left  which  were  not  destroyed,  and  reinfection 
occurs. 

With  the  subsidence  of  the  acute  symptoms  the  strength  of  the 
Protargol  solution  may  be  increased  to  V2  or  1  per  cent.,  and  it 
should  be  used  three  or  four  times  a  day. 

After  Protargol  has  been  continued  a  few  days  longer  it  is  de- 
sirable to  discontinue  its  use  and  begin  with  Largin  solutions,  com- 
mencing with  V^-per-cent.  solutions  and  increasing  to  V2  and  1 
per  cent.,  three  times  a  day. 

It  is  proven  that,  while  Largin  is  not  a  neutral  solution  and  has 
slightly  irritating  qualities,  it  possesses  the  power  of  pene;trating 
more  deeply  than  Protargol,  and  destroying  the  gonococci  lying  in 
the  deep  tissues. 


40  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

After  a  few  days  more  of  treatment  the  discharge  ceases  en- 
tirely, but  few  shreds  are  present,  and  the  gonococci  are  only  found 
in  very  small  numbers  in  the  secretions;  but,  if  the  injections  are 
stopped,  the  gonococci  still  remaining  increase  in  numbers,  and  cause 
a  relapse. 

The  indications  at  this  time  are  to  destroy  the  few  remaining 
gonococci  and  to  cure  the  catarrh  of  the  mucous  membrane. 

This  is  accomplished  by  the  combined  use  of  antiseptics  and 
astringents,  and  to  that  end  1-per-cent.  Largin  solution  may  be  used 
once  a  day,  and  Ultzmann's  injection  of  zinc,  alum,  and  carbolic  acid 
twice  a  day. 

Later  on,  when  the  number  of  shreds  is  very  much  reduced, 
Largin  may  be  used  twice  a  day  and  either  nitrate  of  silver  or 
Argentamin  solution  (V4  or  ^/o  of  1  per  cent.)  may  be  injected  once 
daily. 

A  great  advantage  of  the  treatment  with  silver  salts,  whicb  may 
also  be  assisted  by  the  internal  use  of  sandal-wood  oil,  is  that  the 
disinfection  of  the  tissues  advances  rapidly  and  the  spread  of  the 
inflammation  is  checked;  so  that,  while  under  ordinary  treatment 
posterior  urethritis  occurs  in  80  per  cent,  of  the  cases,  in  the  patients 
treated  with  silver  salts  posterior  urethritis  is  observed  in  from  only 
30  to  40  per  cent,  of  cases. 

In  point  of  time,  while  a  small  percentage  of  cases  are  cured 
in  from  two  to  three  weeks,  under  the  treatment  with  silver  salts, 
in  the  great  majority  of  patients  in  which  complications  do  not 
occur  a  continuous  course  of  medication  of  five  to  six  weeks  is  re- 
quired in  order  to  effect  a  cure. 


CHAPTER    IV, 

POSTERIOR  URETHRITIS. 

Posterior  iirethritis  consists  in  an  inflammation  of  the  mucous 
membrane  of  the  posterior  urethra,  which  lies  behind  the  cut-off 
muscle.  In  severe  cases  the  inflammation  may  extend  up  out  of  the 
urethra  and  involve  the  base  of  the  bladder. 

Acute  posterior  urethritis  is  almost  always  caused  by  the  exten- 
sion of  a  gonorrhoeal  or  simple  urethritis  from  the  anterior  part  of 
the  canal;  but  the  subacute  and  chronic  forms  may  be  the  result  of 
prolonged  congestion  from  sexual  abuses,  complicated  by  germ  in- 
fection from  the  rectum  or  from  without. 

Posterior  urethritis  is  a  serious  complication  of  gonorrhoea, 
because 

I.  It  increases  the  extent  of  the  inflamed  surface  and  renders 
recovery  more  remote. 

II.  On  account  of  complications,  which  are  almost  sure  to  follow, 
if  the  pus  is  conveyed  through  the  various  ducts  opening  into  the 
posterior  urethra,  to  the  prostate,  seminal  vesicles,  testicles,  and 
bladder. 

Posterior  urethritis  occurs  in  80  per  cent,  of  cases  of  gonorrhoea, 
but  is  often  so  mild  as  to  be  overlooked.  It  usually  develops  from 
the  second  to  the  fourth  week,  or  when  the  gonorrhoeal  inflammation 
has  extended  to  the  bulb.  It  may  be  excited  by  the  use  of  a  sound 
or  catheter  in  an  acutely  inflamed  urethra,  which  pushes  the  pus 
along  in  front  of  the  instrument  or  causes  traumatism,  or  it  may 
develop  spontaneously. 

The  membranous  urethra,  in  certain  cases,  acts  as  a  barrier  to 
the  spread  of  an  inflammation  from  the  anterior  urethra  backward 
toward  the  bladder.  The  cut-off  muscle,  which  surrounds  the  mem- 
branous urethra,  is  in  a  state  of  tonic  contraction,  and  acts  like  a 
valve,  and  the  mucous  membrane  lining  the  membranous  urethra  is 
less  vascular  and  provided  with  fewer  crypts  and  follicles  than  either 
the  anterior  or  posterior  urethra,  and  also  serves  to  check  the  exten- 
sion of  the  gonorrhoea. 

Clinically  two  forms  of  posterior  urethritis  are  met  with:  (a) 
mild  or  subacute  form;    (b)  severe  form. 

(41) 


42  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

SYMPTOMS. 

The  symptoms  of  the  mild  form  may  be  so  slight  as  not  to 
attract  attention.  There  is  an  ill-defined  sense  of  weight  over  the 
pubes  and  a  feeling  of  pressure  in  the  perineum,  together  with 
slightly  increased  frequency  of  urination. 

The  symptom  of  increased  frequency  of  urination  depends  upon 
the  fact  that,  in  a  condition  of  health,  the  posterior  urethra  is  the 
most  sensitive  part  of  the  canal,  and,  when  the  bladder  becomes 
filled  and  a  few  drops  of  urine  trickle  into  the  posterior  urethra,  their 
presence  sets  up  a  certain  ph3'siological  irritation,  which  is  trans- 
mitted to  the  bladder,  and  produces  a  contraction  of  its  muscular 
walls,  which  empties  the  bladder  of  its  contained  urine. 

In  posterior  urethritis  there  is  a  congested  state  of  the  pro- 
static urethra  and  an  abnormally  acute  sensitiveness;  so  that  the 
stimulus  to  urinate  is  greatly  increased. 

In  the  severe  form  of  posterior  urethritis  the  symptom  of  fre- 
quent and  painful  urination  is  very  much  aggravated.  If  the  in- 
flammation is  very  acute  and  particularly  if  it  has  extended  to  the 
base  of  the  bladder,  violent  vesical  tenesmus  sets  in,  which  the 
patient  cannot  restrain. 

The  squeezing  together  of  the  inflamed  surfaces,  by  the  muscular 
contractions  of  the  bladder,  not  only  causes  intense  pain,  but  also 
often  ruptures  some  of  the  capillaries  in  the  mucous  membrane;  so 
that  a  few  drops  of  blood  generally  follow  the  act  of  urination. 

No  sooner  has  one  spasmodic  contraction  of  the  bladder  sub- 
sided than  another  one  sets  in,  and  these  continue  to  recur  every  few 
minutes  until  the  suffering  becomes  almost  unbearable. 

DIAGNOSIS. 

The  diagnosis  of  the  severe  form  of  posterior  urethritis  can 
usually  be  made  from  the  symiptoms  alone,  but  the  mild  form  is  apt 
to  be  overlooked,  unless  we  direct  our  patient  with  gonorrhcea  to 
urinate  in  two  glasses,  each  day  we  see  him,  and  in  this  way  we  can 
detect  inflammation  of  the  posterior  urethra  in  its  incipiency. 

The  two-glass  urine  test,  as  devised  by  Sir  Henry  Thompson,  is 
based  upon  the  physiological  action  of  the  cut-off  muscle,  which,  by 
its  tonic  contraction,  forms  a  barrier  between  the  anterior  and  pos- 
terior urethra.  Fluids  injected  into  the  anterior  urethra  cannot  flow 
back  into  the  bladder,  and  pus  lying  in  the  posterior  urethra  is  pre- 
vented from  flowing  out  through  the  anterior  urethra,  but  escapes 


POSTERIOR  URETHRITIS.  43 

backward  into  the  bladder,  and  renders  the  urine  which  had  accumu- 
lated in  the  bladder  turbid  and  cloudy. 

If  suppuration  is  going  on  in  the  anterior  urethra  (the  posterior 
urethra  being  healthy),  and  the  patient  is  directed  to  urinate,  the 
first  gush  of  urine  washes  out  the  pus,  and  the  urine,  if  caught  in  a 
glass,  appears  turbid.  If  the  remainder  of  the  urine,  which  had 
collected  in  the  bladder  and  is  uncontaminated,  is  passed  into  an- 
other glass,  the  urine  in  the  second  glass  is  clear. 

If  suppuration  is  present  in  both  anterior  and  posterior  regions 
of  the  urethra,  the  first  glass  of  urine  passed  is,  of  course,  turbid, 
from  the  pus  washed  out  of  the  urethra,  and  the  second  glass  will 
be  turbid  also,  because  the  pus  formed  in  the  posterior  urethra  flowed 
back  and  stained  the  urine  which  was  contained  in  the  bladder. 

Turbidity  of  the  urine  is  sometimes  caused  by  urates  or  phos- 
phates. If  uratic  in  origin,  the  cloudiness  clears  up  on  boiling,  and, 
if  phosphatic  in  character,  a  few  drops  of  nitric  or  acetic  acid  will 
render  it  clear.  The  presence  of  pus  can  be  determined  by  micro- 
scopic examination  or  by  adding  a  few  drops  of  liquor  potassEE  to 
the  suspected  urine,  in  a  test-tube,  and  twirling  it  rapidly.  If  pus  is 
present  it  will  be  coagulated  and  float  in  long,  ropy  strings  through 
the  urine. 

Chemical  examination  shows  more  albumin  than  can  be  ac- 
counted for  by  the  pus.  This  superabundance  of  albumin  is  not 
occasioned  by  structural  changes  in  the  kidney,  but  to  increased 
intrapelvic  pressure,  caused  by  the  frequent  and  severe  muscular 
spasms  of  the  bladder. 

TREATMENT  OF  THE  MILD  FORM  OF  POSTERIOR  URETHRITIS. 

The  irrigation  of  the  urethra  and  the  bladder  by  means  of  an 
irrigator,  after  Janet's  method,  is  particularly  adapted  to  cases  of 
inflammation  of  the  posterior  urethra  developing  in  the  course  of  a 
gonorrhoea.  Irrigation  of  the  posterior  urethra  can  also  be  practiced 
by  introducing  a  soft-rubber  catheter  beyond  the  cut-off  muscle  so 
that  its  eye  lies  in  the  posterior  urethra,  and  injecting  solutions 
through  it  by  means  of  a  large  hard-rubber  syringe.  The  best  solu- 
tions to  use  are:  Nitrate  of  silver,  1  in  4000  to  1  in  2000,  or  per- 
manganate of  potash,  1  in  6000  to  1  in  1500;  and  both,  of  course, 
should  be  used  hot. 

Instead  of  using  copious  flushings  of  the  urethra,  with  a  con- 
siderable quantity  of  fluid,  we  can  deposit  a  few  drops  of  a  concen- 


44  DISEASES  OF  THE  L'KETHRA  AND  ITS  ADNEXA. 

trated  solution  of  nitrate  of  silver  directly  upon  the  surface  of  the 
mucous  membrane  by  means  of  Ultzmann's  syringe.  The  syringe  is 
introduced  past  the  cut-off  muscle,  so  that  the  end  lies  in  the  pos- 
terior urethra,  and  15  or  20  drops  of  the  solution  are  injected. 
Nitrate  of  silver,  in  strength  ranging  from  1  to  5  grains,  is  the  best 
application  for  the  purpose. 

If  we  desire  to  medicate  the  posterior  urethra  alone,  the  patient 
should  retain  some  urine  in  the  bladder.  The  urine  will  neutralize 
the  solution  as  it  flows  into  the  bladder.  If  a  urethro-cystitis  be 
present,  the  patient  should  empty  his  bladder  first,  and  the  injected 
fluid  will  then  medicate  the  posterior  urethra  and  flow  back  and 
affect  the  base  of  the  bladder  as  well. 

As  to  a  selection  between  the  methods  of  irrigation  and  instilla- 
tion, as  a  general  rule,  it  is  found  that  recent  cases  with  an  abun- 
dant purulent  secretion  and  which  are  free  from  pain  or  other  acute 
symptoms  are  most  benefited  by  copious  irrigations,  and  that  after 
the  discharge  has  diminished,  so  that  the  urine  is  clear  and  only 
shreds  are  present,  instillations  are  more  serviceable. 

Diuretics — such  as  triticum  repens,  uva  ursi,  buchu,  etc. — are 
not  indicated  in  posterior  urethritis,  since,  although  they  render  the 
urine  bland  and  unirritating,  they  increase  the  quantity  secreted, 
and  occasion  more  frequent  calls  on  the  bladder  to  empty  itself. 


TREATMENT  OF  THE  SEVERE  FORM  OF  POSTERIOR  URETHRITIS. 

In  this  form  any  kind  of  mechanical  interference  with  the 
urethra — such  as  injections,  irrigations,  or  the  introduction  of  any 
instrument — shoiild  be  rigidly  avoided.  The  patient  should  go  to  bed 
in  order  to  secure  rest  for  the  inflamed  posterior  urethra,  lessen  its 
congested  condition,  and  so  diminish  the  vesical  tenesmus. 

A  mild  saline  cathartic  is  useful  by  reducing  the  congestion  of 
the  pelvic  organs.  Milk  should  be  the  staple  article  of  diet,  to  render 
the  urine  bland  and  unirritating.  Sandal-wood  oil  acts  almost  like 
a  specific  in  some  cases.  After  a  few  doses  the  tenesmus  lessens  and 
the  escape  of  blood  after  urination  ceases. 

Alkalies  or  alkaline  mineral  waters  are  contra-indicated,  for  the 
reason  that  the  urine  in  the  bladder  is  necessarily  neutral  or  alkaline 
in  reaction,  on  account  of  the  abstinence  from  meat  and  the  milk  diet 
ordered.  If  the  urine  becomes  alkaline  and  pyogenic  micro-organisms 
make  their  way  into  the  bladder  from  without,  a  suppurative  cystitis 


POSTERIOR  URETHRITIS.  45 

is  almost  sure  to  occur;  so  that  a  moderate  degree  of  acidity  of  the 
urine  is  regarded  as  the  best  prophylactic  against  cystitis. 

In  order  to  maintain  this  condition  of  acid  urine,  it  has  been 
advised  of  late  to  administer  salicylate  of  soda,  gr.  xx  three  times  a 
day,  as  this  drug  has  the  property  of  causing  a  strong  acid  reaction 
in  the  urine. 

Morphia  is  generally  required  to  relieve  the  excessive  tenesmus 
and  allay  the  frequent  desire  to  urinate.  The  frequent  desire  for 
urination  has  a  bad  effect  upon  the  inflammation,  since  the  con- 
tractions of  the  bladder  cause  an  increase  in  the  hyperjemia  at  its 
base.  Morphia  may  be  given  by  the  mouth,  but  preferably  in  sup- 
pository. 

Hot  sitz-baths  prolonged  for  half  an  hour  and  used  several 
times  a  day  sometimes  lessen  the  tenesmus  and  desire  to  urinate; 


Fig.  8. — Ultzinann's  Syringe. 

but,  wliiJe  useful  as  an  adjuvant,  they  will  hardly  take  the  place  of 
opium. 

When  these  methods  fail  to  relieve  the  tenesmus  and  pain, 
which  may  be  intense,  the  instillation  of  10  drops  of  nitrate  of  silver 
with  an  Ultzmann  syringe  into  the  posterior  urethra  often  succeeds 
in  calming  the  disturbance  in  a  few  hours.  We  begin  with  gr.  j  to 
the  ounce  and  increase  up  to  gr.  v  to  the  ounce,  using  it  every  second 
or  third  day. 

It  is  always  better  to  use  the  instillation  as  a  last  resort,  since 
we  can  lay  it  down  as  a  rule  from  which  there  are  few  departures: 
"Never  to  introduce  an  instrument  into  a  urethra  affected  wath  acute 
inflammation." 

After  acute  symptoms  have  passed  off  the  case  assumes  the 
characteristics  of  the  mild  form  of  posterior  urethritis,  and  can  be 
treated  as  such. 


CHAPTER    V. 

CHRONIC  URETHRITIS. 

Chronic  urethritis  is  one  of  the  most  obstinate  and  difficult 
affections  to  cure  which  the  genito-urinary  specialist  is  called  upon 
to  treat,  unless  the  treatment  is  based  upon  a  knowledge  of  the 
pathological  changes  which  have  taken  place  in  the  tissues,  and  the 
character  and  exact  location  in  the  urethra  of  the  lesions. 

A  case  of  gonorrhcsa  may  be  called  chronic  when  it  has  lasted 
for  ten  or  twelve  weeks. 

Chronic  urethritis  is  sometimes  incorrectly  called  "gleet"  but 
the  true  definition  of  gleet  is:  A  chronic  muco-purulent  discharge  pro- 
duced in  certain  localized  areas  of  the  mucous  membrane  of  the  urethra 
which  are  in  a  state  of  chronic  catarrhal  or  granular  inflammation. 

The  statement  that  every  case  of  gleet  is  dependent  upon  a 
stricture  is  an  incorrect  one.  A  gleety  discharge  may  be  occasioned 
by  superficial  changes  in  the  mucous  membrane,  which  never  produce 
any  narrowing  of  the  urethra.  On  the  other  hand,  in  cases  where 
stricture  does  exist,  the  mucous  membrane  lying  above  is  never 
healthy,  and  a  gleety  discharge  is  always  present. 

The  predisposing  causes  of  chronic  urethritis  may  be  summed 
up  as  follows:  Anything  which  tends  to  prolong  or  prevent  the 
natural  healing  of  a  gonorrhoea,  such  as:  (a)  Careless  ways  of  living 
on  the  part  of  the  patient.  (&)  Injections  which  are  too  strong  or 
used  too  frequently,  (c)  Use  of  alcohol  or  beer,  {d)  Sexual  inter- 
course or  erotic  excitement. 

At  other  times  cases  which  are  properly  treated  and  which 
have  had  good  care  become  chronic,  usually  on  account  of  some 
diathetic  taint,  either  tuberculosis,  rheumatism,  gout,  or  sometimes 
incipient  pulmonary  phthisis. 

It  is  convenient  to  study  chronic  inflammation  of  the  anterior 
urethra  by  itself,  although  the  posterior  urethra  is  apt  to  be  affected 
as  well,  at  the  same  time. 
(46) 


CHRONIC  ANTERIOR  URETHRITIS. 


47 


CHRONIC  ANTERIOR  URETHRITIS. 

PATHOLOGY. 

As  a  result  of  gonorrhoea,  particularly  in  its  later  stages,  an 
infiltration  of  small  round  cells  takes  place.  This  infiltration  is  the 
most  important  characteristic  of  the  disease,  and  most  of  the  other 
changes  in  the  tissues  result  from  it.  The  small  round  cells  originate 
partly  from  the  capillary  vessels  of  the  mucosa  and  partly  from  a 
proliferation  of  the  fixed  connective-tissue  cells. 


Fig.  9. — Diagram  of  a  Cross-section  of  the  Urethra,  Representing  the 
Histological  Changes  in  Chronic  Urethritis. 


The  small  round-celled  infiltration  begins  in  the  submucous 
connective  tissue  and  surrounds  the  lumen  of  the  urethra  completely. 

Its  favorite  points  of  location  are  most  frequently  around  the 
bulbous  urethra,  and  next  in  frequency  at  the  fossa  navicularis. 
These  are  the  widest  and  mpst  dilatable  portions  of  the  canal,  and 
in  acute  gonorrhoea  the  stream  of  urine  is  not  sufficient  to  wash  out 
the  pus,  which  stagnates  here  and  acts  as  a  focus  for  the  renewed 
local  infection  of  the  tissues  at  these  points. 


48  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

The  mucous  glands  and  follicles  (Littre's  glands  and  Morgagni's 
crypts),  which  dip  down  into  the  meshes  of  the  corpus  spongiosum, 
are  also  surrounded  by  and  imbedded  in  the  infiltration. 

Clinically  we  may  classify  the  cases  of  chronic  urethritis  accord- 
ing to  the  extent  of  the  infiltration  into:  (a)  superficial,  or  mucous, 
form,  in  which  the  small  round-celled  infiltration  is  confined  to  the 
mucous  membrane,  subepithelial  connective  tissue,  and  periglandular 
tissue  alone,  and  which  is  not  followed  by  stricture,  and  (b)  the  deep 
form  of  infiltration. 

In  the  latter  class  the  infiltration  extends  deeply  into  the  tissues, 
and  involves  the  meshes  of  the  corpus  spongiosum  extensively  and  is 
always  followed  by  stricture. 

Glandular  Changes. — During  the  course  of  the  gonorrhoea  the 
gonococci  penetrate  into  Morgagni's  crypts  and  Littre's  glands  and 
set  up  an  inflammation  in  the  cavities,  which  is  accompanied  by  an 
infiltration  of  small  round  cells  around  the  ducts  and  walls  of  the 
glands  (periglandular  infiltration). 

The  infiltration  around  the  duct  stifl:ens  it  and  keeps  its  mouth 
open  and  gaping,  affording  an  open  gateway  for  the  escape  of  the 
inflammatory  products  w^hich  have  formed  within  the  cavity  of  the 
gland. 

The  gonococci  may  continue  to  propagate  within  the  cavities  of 
the  glands  for  months,  after  the  inflammation  has  entirely  ceased 
on  the  free  surface  of  the  mucous  membrane. 

The  reappearance  of  an  acute  purulent  discharge  containing 
gonococci,  a  so-called  relapse,  is  due  to  an  escape  of  gonococci  from 
the  glands  a^nd  a  reinfection  of  the  surface  of  the  mucous  membrane. 

Infection  of  wives  and  mistresses  with  gonorrhoea,  during  coitus, 
is  often  caused  in  the  same  way,  viz.:  the  escape  of  pus-cells  contain- 
ing gonococci,  which  had  been  formed  by  the  suppurative  process 
continuing  in  the  gland-cavities  after  the  surface  of  the  mucous  mem- 
brane had  been  well  for  months.  During  intercourse  the  pus,  mixed 
with  seminal  fluid,  is  deposited  in  the  vagina  of  the  female,  and  in- 
fection follows. 

The  inflammatory  products,  consisting  of  desquamated  epi- 
thelial cells,  pus-cells,  and  granular  material,  which  stuff  the  cavities 
of  the  glands,  are  washed  out  by  the  act  of  urination  and  appear 
floating  about  in  the  urine  as  shreds. 

The  small  granules  are  probably  formed  in  the  glands  of  the 
anterior  urethra,  and  the  larger  plugs,  shaped  like  a  comma  or  tad- 


CHRONIC  ANTERIOR  URETHRITIS. 


49 


pole  (Fuerbringer's  hooks),  originate  in  the  follicles  of  the  prostatic 
urethra. 

Larger  "clap-shreds"  are  also  always  present,  and  are  occasioned 
by  the  secretion  from  erosions  drying  upon  the  surface,  forming  a 
scab,  which  is  washed  away  by  the  stream  of  urine. 

Changes  in  the  Mucosa. — During  the  acute  inflammatory  stage 
of  a  gonorrhoea  the  cylindrical  epithelium  lining  the  urethra  is 
loosened  and  thrown  off  in  patches,  leaving  superficial  erosions.  These 
losses  of  epithelium,  except  in  very  rare  instances,  are  not  deep  enough 
to  deserve  the  name  of  ulcers. 

On  account  of  the  round-celled  infiltration  of  the  submucous 
tissues  the  erosions  do  not  heal  readily,  but  remain  uncovered  by 
epithelium  for  a  long  time. 

The  blood-vessels  in  the  submucous  tissues  send  up  newly- 
formed  capillary  loops,  which  traverse  the  infiltration  in  an  upward 
direction,  and  as  they  grow  toward  the  surface  penetrate  the  floor 
of  the  erosion  and  convert  it  into  a  bed  of  newly-formed  granulations. 


£'^fX>  S  '  O /iy      A/£/>i^ 


Fig.  10. — Diagram  of  a  Section  of  the  Urethra,  Representing  the 
Histological  Changes  in  the  Formation  of  a  Granular  Patch  in  Chronic 
Urethritis. 


These  "granular  patches"  resemble  an  ulcer  in  any  part  of  the 
body  after  it  has  become  covered  with  luxuriant  florid  granulations, 


50  DISEASES  OF  THE  UKETllUA  AND  ITS  ADNEXA. 

which  are  composed  purely  of  capillary  loops,  having  uo  tendency  to 
cicatrize  and  which  are  easily  broken  down  and  destroyed  by  slight 
force. 

In  other  cases  the  mucous  membrane  is  not  eroded  and  there 
are  no  granular  patches  present.  Instead  of  a  loss  of  substance  there 
is  simply  swelling,  congestion,  and  oedema  of  the  mucous  membrane, 
in  scattered  patches,  occasioned  by  its  being  in  a  condition  of  chronic 
inflammation  and  infiltrated  with  leucocytes. 

These  superficial  changes  in  the  mucous  membrane  occasion  a 
continuous  gloety  discharge  until  they  are  healed. 

Final  healing  of  the  lesions  is  brought  about  as  follows: — 

When  the  small  round-celled  infiltration  is  first  deposited,  it  is 
soft  and  succulent,  and  while  in  this  state  it  may  disappear,  entirely 
or  in  part,  by  a  process  of  absorption. 

If  absorption  does  not  take  place,  the  small,  round,  infiltrating 
cells  become  organized,  and  are  replaced  by  true  fibrous  connective 
tissue  of  a  low  grade,  which  goes  on  to  contraction. 

In  a  case  where  the  infiltration  was  of  the  superficial,  or  mucous, 
form,  involving  only  the  mucous  membrane  and  surrounding  the 
glands,  stricture  does  not  follow. 

In  the  deep  form  of  mfdtration,  however,  which  extends  deeply 
into  the  periurethral  tissues  and  involves  the  meshes  of  the  corpus 
spongiosum  extensively,  the  heavy  masses  of  scar-tissue,  into  which 
the  infiltration  becomes  converted,  contract,  impair  the  dilatability  or 
may  materially  decrease  the  calibre  of  the  urethral  canal,  and  form 
stricture. 

After  the  infiltration  which  surrounded  Morgagni's  crypts  and 
Littre's  glands  has  been  converted  into  scar-tissue,  its  subsequent 
contraction  squeezes  the  walls  together;  so  that  the  glands  are  com- 
pressed and  obliterated. 

The  granulations,  which  have  formed  upon  the  erosions,  consist 
simply  of  capillary  blood-vessels,  which  have  been  given  off  from  the 
submucous  vessels  and  have  penetrated  the  infiltration  in  an  upward 
direction.  After  the  formation  of  scar-tissue  its  contraction  squeezes 
the  capillaries  together  and  destroys  them,  and  the  granulations  dis- 
appear as  a  result  of  strangulation. 

The  erosions  become  covered,  not  with  the  normal  cylindrical 
epithelium  of  the  healthy  portions  -of  the  mucous  membrane,  but  by 
many  layers  of  squamous  epithelium. 

The  changes  wrought  by  the  conversion  and  contraction  of  the 


*„ 


^^-.  .,„ 


*if'     . 


.V 


.  V, 


-I      «■ 


4. 


i*        '' 


■•'-   /■v-*."' 


^'J 


III.  Gonorrhoea!  Rheiimatisni. 
Synovial  membrane  infiltrated  with  numerous  intracellular  gonococcl. 


6— 


'•'«&£ 


IV.  Beginning  Stricture. 

a,  Squamous  epithelium  in  many  layers. 
6,  Contracted  connective  tissue. 

c.  Contracted  meshes  of  the  corpus  spongiosum. 

d.  Remains  of  Littre's  gland,  obliterated  through  contraction  of  the  peri- 

glandular and  interstitial  connective  tissue. 


(From  "Die  Syphilis  und  die  Veuerischen  Krankheitea,"  vun  Dr.  Ernest  Finger.) 


CHRONIC  ANTERIOR  URETHRITIS.  51 

sear-tissue  require  from  two  to  ten  years  for  their  completion,  and 
the}^  do  not  proceed  with  a  uniform  degree  of  rapidity;  so  that,  on 
examining  a  case,  all  gradations  of  the  process  may  often  be  seen  at 
tlie  same  time. 

SYMPTOMS. 

There  is  an  absence  of  any  marked  subjective  symptoms;  there 
may  be  at  most  an  occasional  tickling  at  the  meatus. 

The  discharge  from  the  urethra  is  muco-purulent,  thin,  and 
scanty,  and  is  often  so  slight  that  there  is  only  a  drop  in  the  morning 
or  a  sticking  together  of  the  lips  of  the  meatus. 

A  common  feature  of  chronic  urethritis  is  the  exacerbations 
which  are  constantly  occurring.  The  patient  develops  a  profuse 
purulent  discharge,  which  is  checked  very  promptly  by  treatment. 

As  a  result  of  various  indiscretions,  an  acute  inflammation  is 
set  up  in  the  damaged  portions  of  the  urethra,  and  the  discharge 
which  is  produced  in  them  occasions  a  reinfection  of  healthy  portions 
of  the  canal,  as  it  passes  over  them. 

When  a  considerable  extent  of  surface  of  the  mucous  membrane 
is  involved  in  the  inflammatory  process,  if  the  patient  passes  his 
water  into  two  glasses,  the  first  glass  is  turhid  from  the  quantity  of 
pus  washed  out  from  the  canal.  On  microscopic  examination  the 
discharge  is  found  to  be  composed  of  pus-cells,  containing  gonococci 
in  profusion,  desquamated  epithelial  cells,  and  mucus  from  the  crypts 
and  follicles.  After  the  inflammation  is  localized,  and  exists  only 
in  spots,  the  urine  in  the  first  glass  is  no  longer  turbid,  but  shows 
a  few  shreds  floating  in  clear  urine. 

The  presence  of  slireds  always  indicates  that  at  some  point 
along  the  urethra  the  mucous  membrane  is  diseased,  and  a  shred  is 
simply  the  secretion,  which  forms  a  scab  on  the  surface,  and  is  washed 
off  by  the  stream  of  urine.  The  form  of  lesion  may  be  an  erosion 
or  granular  patch  or  a  chronic  catarrh  of  the  mucous  membrane  lying 
over  an  infiltration. 

Microscopic  examination  shows  the  composition  of  shreds  to  be 
pus-cells,  which  may  or  may  not  contain  gonococci,  and  desquamated 
epithelium,  held  together  by  a  quantity  of  mucus. 

In  sliape  shreds  present  themselves  as  heavy  flakes;  long,  slender 
filaments;  tadpole-shaped  bodies,  or  small  granules.  The  heavy 
shreds  always  contain  pus,  and  sink  to  the  bottom,  while  the  light 
filaments  are  composed  entirely  of  squamous  epithelial  cells  and  float. 
The  point  of  practical  clinical  importance  to  determine  is  whether  the 


53 


DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 


Fig.  11. — Shred  from  a  case  of  Gonorrluca  of  long  standing. 
Mixed  Infection  has  occurred.  The  specimen  shows  desquamated 
Squamous  Epithelial  cells,  with  Gonococci  on  their  surfaces,  rus-cells, 
Staphylococci,  and  Streptococci  arranged  in  chains. 

shreds  are  made  up  of  pus-cells  containing  gonococci,  or  whether 
they  are  composed  of  squamous  epithelium  alone,  desquamated  from 
the  healed  surface  of  a  former  lesion. 


DIAGNOSIS. 

The  points  to  determine  in  making  the  diagnosis  of  the  condi- 
tions in  chronic  anterior  urethritis  are: — 

(a)  Whether  a  considerable  surface  of  the  urethral  mucous  mem- 
brane is  involved  in  the  inflammatory  process,  and  secreting  pus 
freely.  When  this  is  the  case  it  is  indicated  by  a  turhid.  cloudy 
appearance  of  the  first  glass  of  urine,  on  making  the  two-glass 
test.     Or 


CHRONIC  ANTERIOR  URETHRITIS. 


53 


(b)  "Whether  the  inflammation  is  no  longer  general,  but  limited 
to  localized  areas.  In  the  latter  condition  the  first  glass  of  nrine  will 
contain  shreds  floating  in  clear  urine. 


Fig.  12. — Otis  Urethiometer. 


Fig  13.  Pig-  14- 

Fig.  13.— Diagram  showing  method  of  detecting  Deep  Infiltration, 

in  Chronic  Urethritis,  with  Bougie  a  Boule  or  Urethrometer. 

Fig.  14. — Diagram  showing  impossibility  of  recognizing  Superficial 

Infiltration,  involving  ISIucous  Membrane  alone,  by  means  of  Bougie 

a  Boule  or  Urethrometer. 


54  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

It  is  equally  important  to  ascertain  if: — 

(c)  The  inflammatory  process  is  superficial;  that  is,  limited  to 
the  mucous  membrane  and  glands,  or  if: — 

{d)  The  infiltration  has  involved  the  meshes  of  the  corpus 
spongiosum,  and  commencing  stricture  is  present.  The  instruments 
useful  in  settling  points  c  and  d  are:  (1)  the  Otis  urethrometer,  (2) 
the  bulbous  bougie,  and  (3)  the  endoscope. 

Otis  TJrethrometer. — MetJiod  of  Using. — The  point  of  greatest 
dilaiahility  of  the  normal  urethra  is  at  the  bulb,  and  on  withdrawing 
the  urethrometer  we  find  that  the  dilatability  of  the  urethra  is 
diminished  gradually  toward  the  meatus,  except  at  the  fossa  navicu- 
laris.  When  a  deep  infiltration  is  present  the  dilatability  of  the 
urethra  is  diminished  abruptly,  but  the  urethral  canal  is  freely 
dilatable  both  befoj-e  and  behind  the  infiltrated  point. 

On  the  other  hand,  superficial  infiltrations  involving  only  the 
mucous  membrane  do  not  extend  into  the  deeper  submucous  tissues 
or  meshes  of  corpus  spongiosum  and  do  not  interfere  wdth  the  dilata- 
bility of  the  urethral  canal. 

It  is  important  to  recognize  deep  infiltrations,  while  they  are 
still  soft  and  recent  and  before  they  have  been  converted  with  scar- 
tissue,  so  as  to  bring  about  their  absorption  and  prevent  the  forma- 
tion of  stricture. 

The  bulbous  bougie,  preferably  the  flexible  variety,  may  be  used 
for  the  same  purpose,  but  is  better  adapted  to  recognizing  infiltra- 
tions which  have  been  transformed  into  scar-tissue  and  begun  to 
contract. 


TREATMENT. 

In  the  cases  of  chronic  urethritis  of  the  superficial  variety — that 
is,  when  the  diseased  condition  is  limited  to  the  mucous  membrane, 
and  does  not  affect  the  deeper  tissues — the  indication  for  treatment 
is  to  bring  the  inflammatory  process  to  an  end  and  promote  the  for- 
mation of  squamous  epithelium  to  cover  the  erosions.  These  indi- 
cations are  fulfilled  by  the  local  application  of  astringent  and  anti- 
septic solutions.  When  general  catarrh  of  the  mucous  membrane  is 
present,  as  indicated  by  turbidity  of  the  first  glass  of  urine,  the 
patient  may  inject  his  urethra  with  an  ordinary  gonorrhoea  syringe, 
and  gradually  increase  the  strength  of  the  injections.     (For  formulae 


CHRONIC  ANTERIOR  URETHRITIS. 


Ob 


see  "Gonorrhoea.")  It  is  preferable,  however,  to  use  an  irrigator, 
which  has  the  advantage  of  distending  the  folds  of  mucous  mem- 
brane and  insuring  a  thorough  contact  of  the  solution  with  its  entire 
surface. 

A  soft-rubber  catheter,  attached  to  a  large-sized  hard-rubber 
syringe  holding  4  ounces,  carried  down  into  the  bulbous  urethra,  may- 
be used,  but  is  not  as  effective  as  the  irrigator. 

The  best  solution  to  use  is  the  nitrate  of  silver,  beginning  with 
1  in  5000  and  increasing  the.  strength  to  1  in  1000. 

Permanganate  of  potash  takes  the  second  place  as  a  curative 
agent,  and  should  be  used  in  the  strength  of  1  in  6000  or  3000  at 
the  beginning  and  gradually  increased  to  1  in  1500. 

In  cases  where  no  micro-organisms  are  present  and  a  simple 
astringent  is  called  for,  Ultzmann's  solution  may  be  used: — 

IJ  Zinei  sulphatis, 

Pulvis  aluminis    aa  gr.  xij. 

Acidi  carbolici, 

Glycerini „  . .  .  .  aa  «(xij. 

Distilled  water   q.  s.  ad  foss. 

Sig. :  Use  half  an  ounce  to  a  pint  of  water,  and  increase  to  one  ounce  to 
a  pint. 

All  these  solutions  should  be  warm,  and  the  irrigations  should 
be  made,  in  general,  every  second  day,  although  occasionally  they 
may  be  of  use  every  day. 

Isolated  Foci. — After  the  disease  has  become  older  and  the  in- 
flammation of  a  considerable  surface  of  the  mucous  membrane  has 
subsided,  it  still  lingers  in  spots  in  the  canal.  It  is  no  longer  general, 
but  localized  to  particular  areas,  and  on  examining  the  urine  the 
first  glass,  instead  of  being  turbid  from  pus,  is  clear,  but  contains 
dap-shreds,  or  filaments,  floating  in  it.  Many  of  the  localized  cases 
heal  under  irrigation,  but  in  those  cases  which  prove  obstinate  con- 
centraied  solutions  must  be  applied  directly  to  the  localized  diseased 
spots  by  means  of  (a)  instillations  with  a  Guyon  or  Ultzmann  syringe, 
{b)  Ultzmann's  brush  apparatus,  or  (c)  the  endoscope  in  very  excep- 
tional cases. 

Instillations. — By  means  of  Guyon's  or  Ultzmann's  syringe  con- 
centrated solutions  of  nitrate  of  silver  can  be  deposited,  drop  by  drop, 
along  the  whole  length  of  the  urethra,  from  the  vesical  sphincter 
to  the  meatus,  thus  bringing  the  medicament  in  contact  with  healthy 
and  diseased  portions  alike. 


50 


DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 


It  is  very  exceptional  for  the  diseased  foci  to  be  so  isolated  that 
they  can  be  treated  in  any  other  way,  even  through  the  endoscope. 

The  indication  for  the  use  of  instillations  of  nitrate  of  silver  is 
considered  to  be  the  presence  of  clap-shreds  floating  in  clear  urine. 

In  a  case  coming  under  treatment,  however,  for  the  first  time, 
instillations  should  never  be  used  until  the  effect  of  irrigations  has 
been  tried,  for  the  treatment  of  chronic  gonorrhoea  is  founded  upon 
the  principle  of  beginning  with  mild  applications  and  gradually  pro- 
ceeding to  the  use  of  stronger  and  more  irritating  measures. 

Another  point  to  bear  in  mind  is  the  fact  that  the  irritation 
caused  by  the  application  of  concentrated  and  caustic  solutions  may 
in  itself  prolong  the  inflammation  and  prevent  the  recovery.  So  that 
it  is  always  desirable,  in  a  case  which  has  been  energetically  treated, 
to  interrupt,  for  two  or  three  weeks,  all  local  applications,  in  order  to 
allow  the  irritation  caused  by  them  to  subside. 


Fig.  15. — Guyon's  Syringe. 


In  beginning  the  treatment  with  instillations,  15  drops  of  a  2- 
grain-to-the-ounce  solution  of  nitrate  of  silver  should  be  used,  which 
causes  some  reaction,  burning  on  urination  and  increased  secretion, 
which  lasts  for  twenty-four  hours  and  then  subsides. 

In  every  case  where  the  presence  of  posterior  urethritis  is  sus- 
pected, the  point  of  the  syringe  should  be  carried  beyond  the  cut-off 
muscle  and  a  few  drops  of  the  solution  deposited  along  the  posterior 
urethra;  and  as  the  syringe  is  withdrawn  the  anterior  urethra  is 
"etched,"  a  drop  at  a  time,  along  its  entire  length. 

The  instillations  should  be  made  every  two  days  and  used  two, 
three,  or  four  times,  or,  in  fact,  as  long  as  a  diminution  in  the  shreds 
is  noted.  By  this  time  the  urethra  has  become  accustomed  to  the 
irritation  of  the  solution,  and  its  strength  must  be  increased  to  5 
grains  to  the  ounce.  The  strength  of  the  soltitions  are  gradually  in- 
creased in  this  way  until  the  patient  is  well  or  until  a  strength  of  25 
grains  to  the  ounce  is  attained. 


CHRONIC  ANTERIOR  URETHRITIS.  57 

The  patieut  may  be  allowed  to  use  a  mild  astringent  injection, 
upon  the  days  when  no  instillation  is  made. 

During  the  course  of  the  treatment  exacerhations,  accompanied 
by  vesical  tenesmus,  free  suppuration,  and  turbidity  of  both  glasses 
of  urine,  occur  at  times.  When  these  happen,  the  instillations  must, 
of  course,  be  suspended  and  either  sandal-wood  oil  or  salicylate  of  soda 
given  by  the  mouth,  or,  if  the  exacerbation  is  not  very  severe,  the 
case  may  be  treated  by  irrigations  until  the  urine  is  again  free  from 
pus,  when  the  instillations  may  be  resumed. 

Cases  of  chronic  anterior  urethritis  which  are  several  years  old, 
and  where  the  pathological  changes  of  erosion  and  granulation  forma- 
tion are  very  extensive  and  the  gonococei  have  entirely  disappeared 
from  the  tissues,  sometimes  resist  the  nitrate-of-silver  applications. 
In  such  cases  Finger  recommends  instillations  of  sulphate  of  copper, 
beginning  with  25  grains  to  the  ounce  and  increasing  to  50,  75,  and 
100  grains.  This  is  only  to  be  used,  however,  after  the  nitrate  of  silver 
is  found  to  be  ineffective. 

The  first  instillation  of  sulphate  of  copper  is  said  either  to  cause 
a  diminution  in  the  number  of  shreds  or  else,  in  the  event  of  gonococei 
still  being  in  the  tissues,  to  occasion  a  profuse  purulent  discharge. 
Hence  it  is  that  the  presence  of  gonococei  is  considered  a  contra- 
indication to  the  sulphate-of-copper  treatment,  and,  in  the  event  of 
gonococei  being  still  present,  a  reversion  to  the  nitrate  of  silver  is 
again  in  order. 

TJltzmann's  Brush  Apparatus. — A  few  years  ago  a  favorite  method 
of  treating  chronic  anterior  urethritis  was  by  means  of  the  brush 
apparatus,  but  of  late  years  the  treatment  by  irrigations  and  instilla- 
tions has  largely  supplanted  it. 

It  is  usually  the  case  that  when  the  bulb  is  affected  the  re- 
mainder of  the  mucous  membrane  is  by  no  means  healthy.  If  the 
entire  anterior  urethra  is  brushed  over,  by  a  combined  rotary  and 
withdrawing  motion  of  the  brush,  with  a  solution  of  nitrate  of  silver 
from  15  to  25  grains  to  the  ounce  in  strength  and  examined  imme- 
diately afterward  with  the  endoscope,  the  diseased  spots  will  be  seen 
to  be  colored  a  whitish  gray,  while  the  healthy  portions  of  mucous 
membrane  will  appear  unaltered  by  the  nitrate  of  silver.  In  this  way 
the  growth  of  epithelium  is  stimulated  over  the  eroded  spots.  The 
anterior  urethra  should  be  brushed  over  every  second  day  or  even 
every  day.  In  obstinate  cases  of  long  standing  sulphate-of-copper 
solutions  may  be  used  in  the  same  way. 


58  DISEASES  OF  THE  URETHRA  AND  ITS  ADXEXA. 

Treatment  with  the  endoscope  is  only  applicable  to  a  few  cases, 
viz.:  those  in  which  the  disease  process  is  exceedingly  circumscribed, 
and  these  are  exceptional  in  point  of  frequency.  Examination  with 
the  endoscope  determines  that  the  urethra  is  healthy  in  the  main,  but 
that  certain  isolated  spots  are  diseased.  If  the  crypts  and  follicles  are 
affected,  their  walls  are  elevated  and  of  a  dark-red  color  (glandular 
and  periglandular  urethritis),-  or  there  may  be  one  or  two  patches  of 
granulation  in  the  urethra.  In  either  case  we  can  apply  a  strongly 
concentrated  solution  directly  upon  the  diseased  spots,  through  an 
endoscope,  by  means  of  a  cotton  swab,  without  its  coming  in  contact 
with  the  healthy  mucous  membrane. 

Nitrate  of  silver  in  solution  as  high  as  20  per  cent,  or  copper  sul- 
phate up  to  10  per  cent,  can  be  used.  Destruction  of  the  diseased 
glands  with  a  galvano-caustic  is  necessary  only  in  cases  of  extreme 
rarity. 

In  general,  the  value  of  endoscopic  treatment  is  limited,  as  there 
are  very  few  cases  where  the  pathological  changes  are  confined  to 
one  or  two  isolated  spots,  and  in  others  the  cause  of  the  continuance 
of  the  persistent  secretion  are  changes  underneath  the  surface  of  the 
mucous  membrane,  which  are  not  recognizable  by  inspection. 

The  deep  form  of  chronic  anterior  urethritis  in  which,  in  addi- 
tion to  disease  of  the  mucous  membrane,  an  infiltration  composed  of 
small  round  cells  is  present  in  the  submucous  tissues,  even  extending 
into  the  meshes  of  the  corpus  spongiosum,  must  be  treated  on  dif- 
ferent lines  from  the  superficial  variety  of  urethritis.  In  these  cases 
the  infiltration  lying  underneath  the  mucous  membrane  cannot  be 
reached  by  applying  astringent  or  bactericidal  solutions  to  its  surface, 
and,  while  the  secretion  may  be  held  temporarily  in  check,  an  ex- 
acerbation occurs  on  the  slightest  provocation. 

The  indications  for  treatment  are: — 

I.  To  promote  the  absorption  of  the  infiltration  and  restore  the 
elasticity  of  the  urethral  wall. 

II.  To  subdue  the  existing  superficial  inflammation  in  the  mu- 
cous membrane  and  glands. 

III.  To  destroy  the  gonococci,  which  are  harbored  in  the  sub- 
stance of  the  infiltration  and  in  the  urethral  glands. 

The  first  indication — that  is,  the  promotion  of  the  absorption  of 
the  infiltration — is  met  by  the  passage  of  a  steel  sound  large  enough  to 
distend  the  urethra  fully  and  put  the  ring  of  infiltration  upon  the 
stretch. 


CHRONIC  ANTERIOR  URETHRITIS.  59 

The  therapeutic  effects  of  the  passage  of  sounds  are: — 

I.  To  allay  urethral  hyperaBsthesia.  The  passage  of  the  sound 
blunts  the  extreme  sensitiveness  of  the  nerve-filaments  and  abolishes 
any  spasmodic  contractions  of  the  muscular  fibres  which  may  be 
present. 

II.  The  infiltration  lying  beneath  the  mucous  membrane  renders 
it  rigid  and  impairs  its  elasticity.  A  sound  large  enough  to  distend 
the  urethra  stretches  the  infiltration  and  causes  small  tears  in  its 
substance  beneath  the  mucous  membrane.  A  traumatic  inflammation, 
with  increased  vascularization,  results  from  these  tears,  and  absorption 
is  stimulated. 

III.  The  passage  of  a  sound  expresses  and  squeezes  out  the  con- 
tents of  the  suppurating  urethral  crypts  and  follicles. 

IV.  The  stretching  of  the  urethral  walls  by  the  sound  breaks 
down  granulations  and  stimulates  the  formation  of  epithelium  upon 
eroded  spots. 

In  order  to  meet  these  indications  it  is  necessary  to  use  a  sound 


Fig.  IjS. — Steel  Sound  with  Van  Buren  Curve. 

of  large  calibre,  which  will  fully  distend  and  stretch  the  urethral 
canal. 

The  sound  should  not  be  passed  too  frequently.  In  cases  of  soft 
and  recent  infiltration  the  intervals  may  be  from  two  to  four  days, 
always  waiting  until  the  reaction  following  has  subsided.  In  cases 
of  hard,  organized  infiltration  the  intervals  should  be  longer:  from 
five  to  eight  days. 

If  the  meatus  is  too  narrow  to  admit  a  sound  of  sufficient  size,  it 
should  be  divided  upon  the  floor. 

There  are,  however,  certain  cases  where  it  is  undesirable  to  en- 
large the  meatus,  as,  for  instance,  in  hypospadias,  and,  again,  there 
are  other  cases  where  the  urethra  is  so  capacious  that  a  No.  30  French 
sound  will  lie  in  it  loosely  without  stretching  the  walls  or  compressing 
the  infiltration.  In  these  cases  recourse  may  be  had  to  the  Oberlaender 
dilator. 

The  action  of  the  dilator  is  to  tear  apart  the  infiltration  under- 


60  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

ni'ath  the  mucous  membrane,  which  remains  intact  without  being 
wounded.  This  is  an  important  feature  of  dilatation,  since  any  fresh 
wound  of  the  mucous  membrane  would  open  up  a  passage  for  renewed 
infection  with  micro-organisms. 

Oberlaender  claims  that  a  fresh  inflammation  starts  up  from  the 
tears  in  the  infiltration,  but  the  increased  vascularization  occasions  its- 
absorption. 

The  dilatation  should  be  very  gradual, — one  or  two  numbers  at  a 
sitting, — and  should  not  be  perform-ed  oftener  than  once  a  week,  and 
care  should  be  taken  not  to  lacerate  the  mucous  membrane.  If  this 
accident  should  occur,  it  will  be  announced  by  haemorrhage  from  the 
meatus. 

It  makes  no  difference,  as  far  as  treatment  is  concerned,  whether 
the  submucoid  round-celled  infiltration  is  soft  and  recent  or  whether 
it  has  been  transformed  into  scar-tissue.  The  indications  in  either 
case  are,  by  dilatation  and  pressure,  to  promote  its  absorption.  Cases 
wjiich  are  quite  recent — that  is,  less  than  from  two  to  six  months  old — 
are  made  worse  by  attempts  at  dilatation.  Cases  in  which  a  consid- 
erable surface  of  mucous  membrane  is  involved  ,are  unsuitable  for  dila- 
tation, until  the  catarrh  has  been  checked  by  irrigations  and  the  super- 
ficial process  is  localized  to  a  few  spots  in  the  urethra,  as  denoted  by 
shreds  floating  in  clear  urine. 

The  second  and  third  indications — which  are  to  cure  the  in- 
flammation in  the  mucous  membrane  and  glands  and  destroy  the  gono- 
cocci — have  been  already  considered  under  the  treatment  of  the  super- 
ficial form  of  urethritis,  and  the  measures  adapted  to  these  ends  should 
be  combined  with  the  dilatation. 

It  is  always  desirable  to  use  irrigations  after  dilating  with  a  sound 
or  dilator.  The  folds  of  the  mucous  membrane  are  smoothed  out  by 
the  pressure  of  the  sound  and  the  solution  comes  in  contact  with  the 
whole -surface.  If  small  tears  have  occurred  in  the  mucous  membrane 
from  stretching,  the  irrigating  fluid  seals  them  up  and  prevents  in- 
fection. 

Instillations  of  concentrated  solutions  are  not  admissible  upon 
the  same  day  of  the  dilatation,  but  should  only  be  used  two  or  three 
days  later. 


CHRONIC  POSTERIOR  URETHRITIS.  61 

CHRONIC  POSTERIOR  URETHRITIS. 

The  posterior  urethra  is  involved  in  about  80  per  cent,  of  all  cases 
of  acute  gonorrhoea.  In  many  of  these  the  disease  never  becomes 
chronic,  but,  when  it  does,  the  posterior  urethra  remains  inflamed 
quite  as  often  as  the  anterior. 

Chronic  posterior  urethritis  may  exist  alone,  the  inflammation 
having  run  its  course  and  ended  in  the  anterior  part  of  the  canal,  but 
we  frequently  find  a  chronic  inflammation  of  both  anterior  and  poste- 
rior portions  of  the  urethra,  at  the  same  time. 

Acute  posterior  urethritis  is  almost  invariably  caused  by  gonor- 
rhoea, but  a  chronic  inflammation  can  be  occasioned  in  other  ways. 
Any  cause  which  tends  to  produce  a  prolonged  state  of  congestion  in 
the  posterior  urethra  which  is  oft  repeated  will,  in  time,  lead  to  the 
establishment  of  a  condition  of  inflammation  in  the  mucous  membrane 
and  hyperplasia  of  the  submucous  tissues. 

The  causes  which  are  usually  responsible  for  these  conditions  are 
excessive  sexual  intercourse  or  sexual  abuses,  such -as  masturbation  or 
coitus  reservatus  (withdrawal). 

For  all  practical  purposes,  the  symptoms  and  treatment  of  chronic 
posterior  urethritis  may  be  considered  together,  without  regard  to  its 
etiology. 

PATHOLOGY. 

On  account  of  the  abundant  supply  of  glands  and  follicles  and 
the  thickness  and  vascularity  of  the  mucous  membrane  the  pus-forma- 
tion is  apt  to  linger  in  the  posterior  urethra  for  years,  and  is  very 
apt  to  attack  the  prostate  and  seminal  vesicles. 

The  histological  changes  are  substantially  the  same  as  in  chronic 
anterior  urethritis. 

The  mucous  membrane  is  in  a  state  of  chronic  inflammation,  with 
desquamation  of  its  epithelium,  and  the  submucous  tissues  are  the 
seat  of  a  small  round-celled  infiltration,  which  also  surrounds  the  mu- 
cous crypts.  The  infiltration,  in  time,  becomes  converted  into  scar- 
tissue  and  the  glands  are  obliterated  by  its  pressure.  The  infiltration, 
however,  is  not  transformed  into  distinct  hands  of  scar-tissue,  such  as 
form  strictures  in  the  anterior  urethra,  but  there  is  simply  a  general 
condensation  or  fibrous  hardening  of  the  periurethral  tissues. 

The  sclerosis  of  the  submucous  tissue  does  not  materially  nar- 
row the  calibre  of  the  urethra,  and,  consequently,  stricture  never  oc- 
curs in  the  posterior  urethra,  except  from  traumatic  origin. 


62  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

The  verumontanum,  or  colliculus  seminalis,  is  always  affected  in 
chronic  posterior  urethritis.  It  is  enlarged,  the  mucous  membrane 
is  bluish  in  color  and  softened,  and  the  natural  sensitiveness  is  ag- 
gravated to  a  high  degree.  This  structure  is  the  point  most  highly 
supplied  with  nervous  filaments  in  the  urethra,  and,  on  account  of  its 
increased  receptive  influence  to  painful  impressions,  when  the  sub- 
mucous infiltration  begins  to  contract  it  compresses  these  nerves  and 
occasions  marked  reflex  disturbances. 

The  symptoms  are  often  mental,  and  take  the  form  of  hypo- 
chondria, depression,  irritability,  and  inability  for  sustained  mental 
effort,  or  may  be  neuralgic  in  character  and  referred  to  distant  or  asso- 
ciated organs. 

DIAGNOSIS. 

The  two-glass  urine  test  is  only  applicable  to  cases  where  there  is 
a  considerable  amount  of  pus-formation.  In  the  following  instances 
the  posterior  urethra  may  be  chronically  inflamed  and  the  second  glass 
of  urine  will  not  be  discolored: — 

(a)  When  such  a  small  quantity  of  pus  is  secreted  that  it  does 
not  flow  back  and  discolor  the  urine  in  the  bladder. 

(&)  When  the  stream  of  urine  is  feeble  in  force  and  not  sufficient 
to  wash  out  the  mucous  plugs  from  the  crypts  and  follicles.  Contrac- 
tion of  the  muscular  structures  surrounding  the  urethra  is  necessary 
to  accomplish  their  emptying. 

(c)  The  prostatic  crypts  and  seminal  vesicles  may  be  chronically 
inflamed  and  yet  the  pus  formed  does  not  flow  out  freely  enough  to 
appear  in  the  urine  unless  direct  pressure  is  made  upon  those  organs 
by  means  of  the  finger  in  the  rectum. 

The  Jadassohn -Van  Zeiss!  method  is  useful  in  overcoming  objec- 
tions a  and  &.     The  technique  is  as  follows: — 

The  anterior  urethra  is  irrigated  by  means  of  a  catheter  attached 
to  a  syringe  or  irrigator,  which  is  carried  down  to  the  cut-off  muscle. 
After  the  anterior  urethra  has  been  thoroughly  cleansed  the  patient 
urinates  in  a  glass,  and  the  urine  contains  the  pus  or  shreds  washed 
out  from  the  posterior  urethra.  The  patient  then  passes  the  remainder 
of  his  urine  into  another  glass,  which  represents  the  condition  of  the 
urine  which  had  accumulated  in  the  bladder. 

After  both  anterior  and  posterior  urethras  have  been  cleansed  of 
accumulated  secretions  by  washing  out  and  urinating,  the  secretions 
from  the  prostatic  follicles  and  seminal  vesicles  should  be  collected  by 


CHRONIC  POSTERIOR  URETHRITIS.  63 

means  of  Jadassohn's  expression  urine  test.  By  means  of  a  finger  in 
the  rectum  a  pressure  or  massage  is  exerted  upon  the  prostate  gland, 
and  the  seminal  vesicles  and  their  contents  are  squeezed  out  into  the 
urethra.  The  patient  then  urinates  and  washes  out  the  expressed 
secretions  into  a  glass.  The  urine  in  the  glass  containing  the  secre- 
tions expressed  from  the  prostate  and  vesicles  is  called  the  expression 
wine. 

In  examining  cases  of  chronic  posterior  urethritis  we  should  al- 
ways pay  particular  attention  to  the  condition  of  the  seminal  vesicles 
and  prostatic  follicles.  These  organs  are  very  liable  to  be  affected 
by  an  extension  of  the  gonorrhoeal  inflammation  from  the  urethra, 
and  when  once  attacked  the  gonococci  are  very  likely  to  remain  in 
them  and  continue  to  propagate  for  months  and,  indeed  in  some  cases, 
for  years. 

SYMPTOMS. 

If  the  posterior  urethra  alone  is  diseased,  there  is  an  absence  of 
purulent  discharge  from  the  meatus. 

In  the  later  stages  of  the  disease  there  is  but  very  slight  pus- 
formation,  simply  a  congestion  of  the  mucous  membrane,  with  an  in- 
filtration and  condensation  of  the  submucous  tissues.  But  in  the  early 
stages  and  in  exacerbations,  the  pus-formation  may  be  in  considerable 
quantity,  and  will  be  easily  shown  by  making  the  two-glass  urine  test. 

On  account  of  the  chfonic  inflammation,  the  posterior  urethra  is 
always  in  a  state  of  exaggerated  sensitiveness,  and  the  necessity  for 
frequent  urination  is  nearly  always  present.  Usually  the  desire  to 
urinate  is  so  urgent  that  the  patient  cannot  wait,  but  must  respond  at 
once  to  the  call,  or  the  urine  escapes  and  wets  his  clothing. 

Sexual  symptoms  are  nearly  always  prominent.  The  sexual  ap- 
petite is  disturbed.  There  is  either  no  inclination  for  coitus  and,  if 
indulged  in,  a  condition  of  general  nervous  depression  follows,  or 
else  there  may  be  a  constant  desire  for  sexual  intercourse,  which  is 
not  satisfied  by  indulgence. 

The  act  of  coitus  is  not  satisfactorily  performed.  Ejaculation 
occurs  prematurely  on  account  of  the  irritable  condition  of  the  poste- 
rior urethra,  and  for  the  same  reason  seminal  emissions,  or  pollutions, 
occur  at  night  during  sleep,  more  frequently  than  is  natural,  and  in 
some  cases  the  seminal  discharges  may  be  stained  with  blood,  which 
is  derived  either  from  the  congested  posterior  urethra  or  else  from  an 
inflamed  condition  of  the  interior  of  the  seminal  vesicles. 


64  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

Mental  symptoms  are  a  striking  feature  of  most  cases  of  posterior 
urethritis.  The  patients  are  hypochondriacal,  they  suffer  from  de- 
pression of  mind,  and  are  low-spirited,  melancholy,  and  despondent, 
and  in  extreme  cases  may  have  suicidal  impulses.  In  this  frame  of 
mind  they  fall  an  easy  prey  to  quacks  and  charlatans,  whose  adver- 
tisements guaranteeing  to  "restore  lost  manhood  and  relieve  the  evils 
attendant  upon  the  errors  of  youth,"  appear  in  the  columns  of  the 
daily  papers. 

TREATMENT. 

In  chronic  inflammation  of  the  posterior  urethra  resulting  from 
sexual  excesses  or  abuses,  the  anterior  urethra  is  not  involved;  but  in 
posterior  urethritis  caused  by  gonorrhoea  the  anterior  urethra  is  gen- 
erally affected  as  well. 

For  purposes  of  treatment  it  is  well  to  divide  the  cases  of  posterior 
urethritis  into  two  groups: — 

(a)  Superficial,  in  which  the  mucous  membrane  and  glands  alone 
are  involved  in  the  inflammatory  process. 

(b)  Deep  form,  in  which,  in  addition  to  the  inflammation  in  the 
mucous  membrane,  there  is  an  infiltration  in  the  deeper  tissues. 

The  small  round-celled  infiltration  is  deposited  here  and  ulti- 
mately is  converted  into  scar-tissue.  It  does  not  contract  and  form 
fibrous  bands,  but  merely  produces  a  general  condensation  and  hard- 
ening of  the  submucous  tissue. 

In  the  superficial  form,  where  there  is  a  considerable  amount  of 
pus-formation,  irrigation  by  means  of  an  irrigator  or  syringe  and 
soft-rubber  catheter  introduced  beyond  the  cut-off  muscle,  using 
nitrate-of-silver  or  permanganate-of-potash  solution,  will  generally 
check  the  secretion.  After  the  suppuration  has  lessened  instillations 
with  Ultzmann's  syringe,  carried  behind  the  cut-off  muscle  into  the 
posterior  urethra,  of  15  drops  of  a  nitrate-of-silver  solution,  begin- 
ning with  2  grains  to  the  ounce  and  increasing  as  directed  in  the  treat- 
ment of  "Chronic  Anterior  Urethritis,"  usually  causes  a  prompt  dis- 
appearance of  the  remaining  secretion  and  shreds.  If  it  is  desirable 
to  medicate  the  posterior  urethra  without  having  the  nitrate-of-silver 
solution  come  in  contact  with  the  interior  of  the  bladder,  it  is  well  to 
make  the  instillation  with  the  bladder  full  of  urine.  In  that  event  any 
of  the  solution  which  flows  back  into  the  bladder  is  neutralized  by 
the  salts  of  the  urine. 

If,  on  the  other  hand,  we  wish  to  affect  the  base  of  the  bladder 


CHRONIC  POSTERIOR  URETHRITIS.  65 

as  well  as  the  posterior  urethra,  the  bladder  should  be  emptied  of 
urine  before  making  an  instillation. 

In  treating  the  deep  form  of  chronic  posterior  urethritis  the  in- 
dications are: — 

I.  To  cure  the  inflammation  in  the  mucous  membrane. 

II.  To  produce  absorption  of  the  deep-lying  infiltration. 

To  accomplish  these  objects  it  is  necessary  to  employ,  in  addition 
to  the  irrigation  or  instillation,  the  regular  passage  of  sounds.  For- 
cible dilatation  or  tearing  apart  of  the  tissues  is  harmful,  and  we  should 
proceed  with  the  utmost  gentleness  and  caution  in  the  manipulation 
of  sounds  in  this  region.  The  sound,  of  course,  should  never  be  passed 
until  the  free  suppuration  has  ceased  and  there  are  only  very  chronic 
and  indolent  inflammatory  residua  remaining,  on  account  of  the 
danger  of  increasing  the  inflammation  or  of  causing  epididymitis. 


Fig.  17. — Psychrophor,  or  Cold- Water  Sound,  of  Winternitz. 


The  Benique  sound  is  particularly  adapted  to  the  posterior  ure- 
thra, on  account  of  its  shape,  which  is  similar  to  that  which  a  soft 
catheter  assumes  when  it  lies  in  the  bladder  and  urethra.  The  weight 
of  the  Benique  sound  has  some  advantage,  as  it  produces  a  certain 
amount  of  compression  and  so  stimulates  absorption  of  the  infiltration, 
besides  emptying  out  the  crypts  and  follicles. 

The  cases  of  chronic  posterior  urethritis  which  require  the  use 
of  KoUmann's  posterior  dilator  are  exceptional  in  frequency.  When 
the  dilator  is  used  in  the  posterior  urethra  great  care  should  be  exer- 
cised not  to  dilate  too  rapidly  and  so  lacerate  the  tissues  or  excite 
epididymitis,  as  the  tolerance  to  instrumentation  is  far  less  in  the 
posterior  urethra  than  in  the  anterior. 

The  psychrophor,  or  cold-water  sound,  made  preferably  with  the 


GG  DISEASES  OF  THE  URETHRA  AND  ITS  ADXEXA. 

Benique  curve,  is  found  to  be  of  more  benefit  than  the  ordinary  steel 
sound,  in  the  cases  which  develop  a  chronic  sexual  neurasthenia  or 
have  local  symptoms  pointing  to  excessive  irritability  of  the  posterior 
urethra,  such  as  unduly  frequent  seminal  emissions. 

The  psychrophor  should  be  used  every  second  day  for  ten  or 
twenty  minutes.  The  effect  of  the  cold  is  to  diminish  the  hypersensi- 
tiveness  of  the  verumontanum,  and  the  pressure  of  the  sound  acts 
beneficially  in  promoting  absorption. 

In  every  case  of  chronic  posterior  urethritis  the  condition  of  the 
seminal  vesicles  should  be  investigated  by  rectal  examination.  It  is 
useless  to  attempt  to  cure  an  inflamed  posterior  urethra  when  a  pair 
of  inflamed  seminal  vesicles  are  discharging  a  quantity  of  gonorrhoeal 
pus  into  the  urethra  every  few  days  and  causing  an  exacerbation. 
Many  cases  of  relapsing  posterior  urethritis  will  get  permanently  well 
through  a  systematic  stripping  of  the  seminal  vesicles,  when  every- 
thing else  has  been  tried  in  vain. 

At  the  same  time  the  prostate  should  not  be  overlooked,  for  a 
follicular  prostatitis  is  often  present  as  a  complication,  and  should  be 
treated  by  massage  through  the  rectum,  in  order  to  empty  out  the 
contents  of  the  inflamed  and  dilated  prostatic  crypts. 


SUMMARY   OF   TREATMENT   OF   CHRONIC   ANTERIOR   AND 
POSTERIOR   URETHRITIS. 

In  the  great  majority  of  cases  of  chronic  urethritis  a  systematic 
and  regular  course  of  dilatations,  with  sounds  or  Oberlaender's  dilator 
accompanied  by  copious  irrigations  of  weak  astringent  solutions,  will 
be  more  successful  than  any  other  plan  of  treatment.  Before  begin- 
ning dilatation  the  inflammation  of  the  mucous  membrane  should  no 
longer  be  general,  but  confined  to  localized  areas. 

When  the  inflammation  is  general,  the  urine  passed  in  a  glass  is 
turbid  and  cloudy  from  admixture  with  pus,  but  the  localization  of 
the  inflammation  to  isolated  spots  is  indicated  by  shreds  floating  in 
clear  urine. 

After  dilatation  and  irrigations  have  been  carried  out  for  some 
time  and  the  patient  is  not  cured,  as  shown  by  persistence  of  morning 
drop  and  shreds,  concentrated  solution  of  nitrate  of  silver  may  be  ap- 
plied directly  to  the  inflamed  areas  by  means  of: — 

(a)  Ultzmann's  brush  apparatus. 

(b)  Guyon's  or  Ultzmann's  syringe. 


CHRONIC  POSTERIOR  URETHRITIS.  67 

(c)  The  endoscope. 

In  every  case  of  chronic  posterior  urethritis  the  condition  of  the 
seminal  vesicles  and,  prostate  should  be  ascertained,  and,  if  diseased, 
the}^  should  be  treated  by  stripping  or  massage  through  the  rectum. 


PROGNOSIS  OF  CHRONIC  ANTERIOR  AND  POSTERIOR  URETHRITIS. 

The  duration  of  the  disease  is  always  protracted,  and  requires 
great  patience  on  the  part  of  physician  and  patient. 

The  test  as  to  when  the  patient  is  cured  is  the  permanent  absence 
of  pus-cells  and  gonococci  in  the  urethral  secretions. 

When  all  discharge  has  ceased  from  the  anterior  urethra,  in  order 
to  get  material  for  microscopic  examination  it  is  necessary  to  inject 
a  syringeful  of  2-per-cent.  nitrate-of-silver  solution  into  the  anterior 
urethra.  A  free  discharge  of  pus  follows,  which  ceases  in  twenty-four 
hours.  If  no  gonococci  are  found  in  the  resulting  secretion  after 
microscopic  examination  of  several  smears,  it  is  safe  to  conclude  that 
the  micro-organisms  have  all  been  eliminated  from  the  urethra  in 
front  of  the  cut-off  muscle. 

The  secretions  of  the  prostatic  crypts  and  seminal  vesicles  should 
be  expressed  by  the  finger  in  the  rectum  and  examined  at  the  same 
time.  It  is  from  these  organs  that  the  chief  danger  of  infection  comes 
after  discharge  has  ceased  from  the  meatus,  and  they  are  responsible 
for  the  majority  of  cases  of  infection  of  wives  and  mistresses.  In  ex- 
amining the  expressed  secretions  from  the  prostate  and  vesicles  it  is 
not  enough  to  demand  absence  of  gonococci;  we  should  insist  upon 
an  absence  of  pus-cells,  for  if  pus-cells  are  present  there  may  be  an 
occasional  gonococcus  in  a  cell  which  might  easily  be  overlooked. 

It  is  estimated  that  one-eighth  of  all  the  diseases  of  women  are 
occasioned  by  gonorrhoeal  infection  attacking  the  vagina  or  cavity  of 
the  uterus,  and  thence  extending  to  the  Fallopian  tubes  and  ovaries. 
In  view  of  these  facts,  a  patient  who  has  suffered  from  chronic  gonor- 
rhoea should  only  be  allowed  to  marry  when  examination  shows: — 

I.  Absence  of  gonococci. 

II.  Absence  of  pus-cells. 

III.  Freedom  from  stricture. 

IV.  A  healthy  normal  condition  of  prostate  and  seminal  vesicles. 
Certain  cases  of  chronic  urethritis  suifer  from  excess  of  treatment, 

and  the  inflammation  is  maintained  by  the  irritation  produced  by 
the  local  applications. 


68  DISEASES  OF  THE  URETHRA  AND  ITS  ADXEXA. 

After  a  case  has  been  under  treatment  for  a  couple  of  months, 
it  is  always  desirable  to  stop  all  injections  or  instillations  for  ten  days 
in  order  to  make  sure  that  the  natural  process  of  recovery  is  not 
retarded  by  overtreatment. 

Entire  disappearance  of  shreds  is  not  to  be  looked  for.  The  ero- 
sions have  been'  covered  with  many  layers  of  squamous  epithelium, 
and  continuance  of  desquamation  of  the  upper  layers  goes  on  as  the 
new  cells  are  formed  in  the  depths. 

The  shreds  appear  as  thin  filaments  which  float  in  the  urine,  and 
microscopic  examination  shows  them  to  be  composed  of  squamous 
cells  alone  without  containing  any  pus-corpuscles. 

METHOD  OF  EXAMINING  A  CASE  OF  CHRONIC  URETHRITIS. 

First  Day. 

History:    Take  in  detail. 

I.  Inspect  pus  squeezed  from  meatus. 

II.  Examine  urethra  with  bulbous  bougie  or  urethrometer. 

Second  Day. 

III.  Wash  out  shreds  and  secretion  from  anterior  urethra. 

IV.  Patient  urinates  in  glass  No.  1.  No.  1  contains  washings 
from  posterior  urethra. 

V.  Examine  prostate  and  seminal  vesicles  per  rectum. 

VI.  Patient  urinates  in  glass  No.  2.  No.  2  contains  expression 
urine  from  prostate  and  seminal  vesicles. 

VII.  Examine  shreds  and  pus  secreted  by  urethra  microscopic- 
ally. 

Third  Day. 

VIII.  Examine  urethra  with  endoscope  unless  a  considerable  por- 
tion of  the  mucous  membrane  is  inflamed  and  secreting  pus  freely. 


URETHROSCOPY. 

The  use  of  the  urethroscope  or  endoscope  is  disappointing  in 
many  cases,  inasmuch  as  the  diseased  processes  in  the  urethra  occur 
chiefly  underneath  the  mucous  membrane,  and  the  surface  is  often 
but  little  affected. 


URETHROSCOPY.  69 

It  has  a  field  of  great  usefulness,  however,  for  disclosing  and 
treating  diseased  processes  which  are  strictly  localized  to  one  or  two 
isolated  foci,  and  it  is  useful  in  diagnosis  and  also  enables  us  to  observe 
the  effects  of  treatment  by  dilatation  and  irrigation. 

There  are  many  varieties  of  urethroscopes  in  use,  and  after  using 
most  of  them  I  have  come  to  prefer  the  simple  Klotz  tube,  illumi- 
nated by  means  of  a  light  reflected  with  a  head-mirror  from  a  powerful 
central-draft  oil-lamp.  (The  Belgian,  Mitrailleuse,  or  Eochester  lamps 
are  suitable.) 

The  beginner  in  endoscopy  should  select  the  shortest  and  widest 
tube  which  will  pass  the  meatus,  doing  a  preliminary  meatotomy  if 
necessary.  It  is  very  diflficult  for  even  an  experienced  urethroscopist  to 
see  through  a  tube  which  is  less  than  No.  24  French  in  calibre,  and  as 
larger  tubes  are  used  the  examination  becomes  correspondingly  easier. 

The  tubes  which  are  indispensable  are  Nos.  24,  26,  and  30  French, 


Fig.  18. — Klotz  Endoscope, 

each  four  inches  long,  and  Nos.  26  and  28  French,  each  six  inches 
long.  With  the  short  tubes  the  anterior  urethra  is  examined,  and  the 
posterior  urethra  by  means  of  the  long  ones. 

Normal  Appearances  of  Anterior  Urethra. — I.  Observe  the  sur- 
face of  the  funnel-shaped  figure  which  the  urethral  walls  assume 
beyond  the  end  of  the  endoscope. 

II.  The  central  figure:  i.e.,  appearance  presented  by  the  closed 
lumen  of  the  urethra,  which  forms  the  apex  of  the  funnel. 

The  folds  of  mucous  membrane  radiate  from  the  central  figure 
outward  toward  the  periphery.  Their  thickness  and  number  indicate 
if  the  mucous  membrane  be  infiltrated,  and  are  of  diagnostic  impor- 
tance. Longitudinal  red  stripes  running  toward  the  central  figure 
are  also  noted,  and  indicate  a  normal  uninfiltrated  condition  of  the 
mucous  membrane. 

The  surface  of  the  mucous  membrane  is  smooth  and  glistening 
and  with  a  distinct  lustre;   its  color  is  ordinarily  pale  and  rosy,  but 


70  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

if  normally  hyperaemic  may  appear  distinctly  red  or  purple,  without 
being  diseased. 

The  openings  of  Morgagni's  crypts  appear  in  the  roof  of  the 
urethra  as  red  specks  or  small  slits  as  large  as  a  pin's  head. 

The  posterior  urethra  presents  substantially  the  same  appear- 
ances as  the  anterior,  except  that  in  addition  the  verumontanum  is 
seen  upon  the  floor  of  the  urethra  looking  like  a  fold  of  inucous  mem- 
brane. 

In  exceptional  cases  the  ejaculatory  ducts  can  be  seen  as  little 
dots  alongside  the  verumontanum. 


Fig.  10. — Uretliroscopic  picture  of  a  Normal  Urethra,  showing  a 
multitude  of  fine  folds  and  small  Central  Figure. 


Pathological  Changes.  —  Chronic  urethritis  is  divided  into  two 
forms: — 

(a)  Superficial:  i.e.,  affecting  mucous  membrane  and  glands 
without  involving  the  deep  tissues. 

(&)  Deep  form  in  which,  in  addition  to  the  involvement  of  mu- 
cous membrane  and  glands,  a  round-celled  infiltration  occurs  in  the 
deeper  lying  submucous  tissues,  which  is  ultimately  converted  into 
fibrillated  connective  tissue. 


URETHROSCOPY. 


71 


The  new  fibrous  tissue  causes  a  rigidity  of  the  urethra,  and,  as 
it  contracts,  produces  a  narrowing  of  the  urethral  calibre,  or  stricture, 
and  also  destroys,  by  compression,  the  urethral  glands  which  it  sur- 
rounds. 

On  viewing  a  case  of  the  superficial  form  of  chronic  urethritis 
endoscopically,  we  note  a  swollen,  oedematous,  and  puffy  condition  of 
the  mucous  membrane  at  the  diseased  points.  The  folds,  instead  of 
being  numerous  and  fine,  are  thick  and  broad. 

Attention  should  be  paid  to  the  lustre  of  the  mucous  membrane. 


Fig.  20. — Urethroscopic  picture' of  Soft  Infiltration  of  tlie  Mucous 
and  Submucous  Tissues.  The  Central  Figure  is  Wide  and  Gaping,  and 
the  Folds  of  Thickened  Mucous  Membrane  are  Few  in  Number  and 
Coarse  and  Broad. 


The  epithelial  layer  forms  a  smooth  transparent  covering  with  a  dis- 
tinct uniform  lustre,  which  is  increased  when  the  mucous  membrane 
is  congested  and  swollen,  and  diminished  when  it  is  infiltrated  or  when 
the  epithelium  is  desquamated. 

Erosions  occur  in  consequence  of  the  desquamation  of  epithelium, 
which,  when  extensive,  uncovers  the  orifices  of  Littre's  glands.  They 
become  visible  as  small,  round,  red  specks  arranged  in  groups  pro- 


72 


DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 


jecting  above  the  floor  of  the  eroded  surface.  Later  in  the  disease  the 
erosions  often  become  covered  by  a  growth  of  capillary  loops  from 
below,  which  converts  them  into  beds  of  granulations.  These  appear 
of  the  size  of  small  grains  of  sand,  or  may  only  cause  a  papillated  ap- 
pearance upon  the  surface  of  the  mucous  membrane,  and  bleed  freely 
upon  the  introduction  of  the  endoscopic  tube. 

Granulations  are  generally  associated  with  an  infiltration  of  the 
deeper  submucous  tissues. 

In  rare  cases  silver}^- white  spots  may  be  observed  upon  the  sur- 


Fig.  21. — Urethroscopic  picture  of  Hard  Infiltration  of  the  sub- 
mucous tissues.  The  Central  Figure  is  open,  gaping,  and  very  irregu- 
lar in  shape. 


face  of  the  mucous  membrane,  resembling  the  scales  of  psoriasis,  and 
hence  called  by  Oberlaender:  "Psoriasis  of  the  mucous  membrane  of 
the  urethra." 

Morgagni's  crypts  appear,  not  singly,  but  in  groups,  as  small,  red 
points,  or  depressions.  Their  openings  are  swollen  and  are  patulous, 
and  sometimes  pus  can  be  seen  oozing  from  them.  Later  on  in  the 
disease,  after  periglandular  infiltration  has  taken  place,  these  openings 
gape,  and  are  surrounded  by  a  prominent  rim  of  infiltration. 


URETHROSCOPY.  73 

Upon  examining  a  case  of  the  deep  form  of  chronic  urethritis  in 
which  the  infiltration  has  become  converted  into  fibrous  tissue  (hard 
infiltration — Oberlaender),  we  note  that  the  central  figure,  instead  of 
being  round,  is  irregiilar,  and  gaping  widely.  The  folds  of  the  mu- 
cous membrane  have  disappeared  and  the  color  is  grayish. 

Morgagni's  crypts  gape  widely  open,  and  are  often  seen  sur- 
rounded by  a  ring  of  inflammation  (periglandular  infiltration).  Lit- 
tre's  glands  are  sometimes  visible,  appearing  as  red  specks  in  a  grayish, 
discolored  mucous  membrane. 

In  another  class  of  cases  affected  with  deep  infiltration  the  open- 
ings of  the  glands  are  not  apparent,  as  they  are  covered  by  the  epi- 
thelium, which  has  a  dry,  dull  appearance,  and  desquamates  freely  in 
spots. 

According  to  Oberlaender,  under  treatment  by  gradual  dilatation 
the  restoration  of  the  tissues  to  their  normal  condition  can  be  watched 
endoscopically,  and  after  a  chronic  urethritis  has  been  entirely  healed 
the  appearances  are  as  follow: — 

The  epithelial  layer  has  grown  smooth  and  possesses  its  normal 
lustre  and  color.  It  has  regained  its  natural  condition  of  very  minute 
and  abundant  folds.  The  infiltration  disappears  around  the  glands, 
although  their  mouths  may  still  remain  patulous  and  visible.  The 
central  figure  is  round,  instead  of  being  gaping  and  irregular,  and 
cicatrices  from  former  urethrotomies  have  become  smooth  and  even. 

By  means  of  the  endoscope  we  can  diagnose  those  conditions,  of 
rare  occurrence,  in  the  urethra,  consisting  of  polypi  or  papillomata, 
and  we  can  also  distinguish  chancre  of  the  urethra  and  malignant 
disease. 

TREATMENT. 

The  application  of  remedies  is  made  to  the  diseased  surface  by 
means  of  a  tampon  of  cotton  wrapped  around  a  stick^  and  introduced 
through  the  endoscopic  tube.  The  principal  drugs  in  use  are:  nitrate 
of  silver,  from  10  to  100  grains  to  the  ounce;  iodine  and  carbolic  acid, 
equal  parts;  sulphate  of  copper,  25,  50,  or  100  grains  to  the  ounce; 
and  bichloride  of  mercury,  in  1-per-cent.  alcoholic  solution. 

The  intervals  of  treatment  depend  upon  the  amount  of  reaction; 
every  three  days  for  mild  solutions  and  from  five  to  seven  days  for 


^  The  sticks  which  florists  use  for  tying  on  to  the  ends  of  cut  flowers 
answer  the  purpose. 


74  DISEASES  OF  THE  URETHRA  AND  ITS  ADNEXA. 

strong  ones  is  about  the  average.  After  improvement  begins  intervals 
should  be  increased  to  ten  days.  The  first  application  should  always 
be  mild;  10  grains  to  the  ounce  is  strong  enough  to  begin  with,  and 
it  may  be  increased  later  if  desired. 

In  regard  to  the  selection  of  the  appropriate  remed}',  it  may  be 
said  in  a  general  way  that  a  diffuse  hypertemia  calls  for  milder  solu- 
tions of  nitrate  of  silver:  5  or  10  grains  to  the  ounce.  Granulations 
require  strong  solutions  of  nitrate  of  silver,  from  50  to  100  grains,  or 
carbolized  iodine.  For  erosions  mild  solution  of  nitrate  of  silver,  5 
or  10  grains  to  the  ounce,  is  the  best,  while  for  inflamed  glands  car- 
bolized iodine  answers  well. 

The  prostatic  urethra  requires  the  strongest  applications  of  ni- 
trate of  silver;  but  under  inspection,  if  the  lesions  do  not  improve,  the 
strength  of  the  solutions  can  be  increased  or  their  character  changed, 
as  occasion  requires. 

Polypi  and  large  warts  must  be  removed  by  surgical  means,  and 
the  inflamed  glands  which  do  not  yield  to  usual  treatment  can  be 
obliterated  by  electroWsis. 

With  the  deep  form  of  urethritis,  in  addition  to  applications  upon 
the  surface  of  the  mucous  membrane,  we  must  endeavor  by  gradual 
dilatations,  with  sounds  or  dilators,  to  cause  the  disappearance  of  the 
deep-lying  infiltrations. 


COMPLICATIONS  OF  ACUTE 
GONORRHOEA. 


CHAPTER   VL 

ACUTE  GONOERHCEa! 

Balanitis  is  an  inflammation  of  the  mucous  membrane  of  the 
prepuce  and  glans  penis,  and  is  apt  to  occur  in  men  with  a  long  fore- 
skin, and  particularly  in  persons  of  uncleanly  habits. 

The  treatment  consists  in  cleanliness,  the  use  of  a  dusting-powder, 
and  preventing  contact  of  the  opposing  surfaces  of  mucous  membrane 
by  means  of  cotton  packed  between  the  foreskin  and  the  glans.  Occa- 
sionally the  oedema  and  swelling  are  so  great  that  the  foreskin  cannot 
be  retracted,  giving  rise  to  a  condition  of  phimosis. 

Phimosis. — This  should  be  treated  by  prolonged  soaking  of  the 
penis  in  hot  water  and  the  use  of  an  antiseptic  injection  thrown  in 
under  the  foreskin  with  a  flat-billed  Taylor  syringe.  In  the  event  of 
gangrene  threatening  or  when  the  swelling  and  oedema  persist,  the 
operation  of  circumcision  or  making  an  incision  through  the  foreskin 
upon  its  dorsum  is  called  for.  If  chancroids  are  found  under  the  pre- 
puce after  operation,  they  should  be  cauterized  as  well  as  the  freshly 
made  wound. 

Paraphimosis  is  that  condition  in  which  a  long  and  tight  fore- 
skin is  caught  back  behind  the  glans  and  cannot  be  retracted  over  the 
head  of  the  penis. 

The  treatment  consists  in  bringing  the  foreskin  back  into  its 
proper  place  by  manipulation.  If  this  prove  difficult  or  if  the  glans 
looks  gangrenous,  the  constricting  band  should  be  incised  on  the 
dorsum,  which  will  generally  allow  reduction  to  be  effected. 

rolliculitis  consists  in  suppuration  of  one  of  the  urethral  fol- 
licles, with  its  retention,  forming  a  small  abscess,  which,  if  left  to 
itself,  opens  spontaneously  either  into  the  urethra  or  through  the  skin. 

(75) 


76  COMPLICATIONS  OF  ACUTE  GONORRHEA. 

The  treatment  consists  in  laying  the  abscess-cavity  open  freely, 
as  soon  as  fluctuation  is  noticed,  evacuating  the  pus,  and  allowing  it 
to  heal  by  granulation. 

Cowperitis  is  a  suppurative  inflammation  of  Cowper's  glands,  and 
should  be  treated  in  the  same  way  as  folliculitis. 

Inguinal  adenitis  is  an  inflammatory  enlargement  of  the  lym- 
phatic glands  in  the  groin,  which  is  generally  present  in  gonorrhoea. 
The  glands  rarely  suppurate,  but  usually  undergo  resolution. 

The  treatment  consists  in  rest,  hot  or  cold  applications,  and  press- 
ure.   If  suppuration  occur,  the  glands  should  be  excised. 

Chordae  is  a  complication  which  adds  greatly  to  the  discomfort 
of  a  patient  with  gonorrhoea.  It  is  due  to  the  plastic  infiltration  which 
takes  place  into  the  meshes  of  the  corpus  spongiosum,  and  renders  it 
so  rigid  and  inelastic  that  it  cannot  become  elongated  during  erection, 
but  draws  on  the  corpora  cavernosa,  and  bends  them  down,  like  the 
tightened  string  bends  a  bow. 

Treatment  is  directed  toward  preventing  these  painful  erections 
and  allowing  the  patient  to  sleep  undisturbed.  To  this  end  he  should 
use  prolonged  immersions  of  the  penis  in  very  hot  water  before  going 
to  bed,  and  should  sleep  in  a  cool  room,  lightly  covered.  It  is  better 
for  him  to  sleep  on  the  side,  as  the  dorsal  decubitus  favors  congestion 
of  the  centre  of  erection  in  the  cord. 

A  towel  tied  around  the  waist  with  a  knot  in  the  middle  of  the 
back  will  assist  in  this,  for  if  the  patient  lies  on  his  back  the  knot 
will  press  into  the  flesh  and  waken  him. 

In  severe  cases  these  measures  are  not  enough,  and  we  have  to 
administer  sedative  drugs.  Lupulin,  gr.  xxx-xl  at  bed-time;  bromide 
of  potash  in  large  doses,  30  grains  in  the  afternoon  and  again  at  bed- 
time, or  monobromide  of  camphor  in  5-grain  doses  will  sometimes 
answer,  and,  when  they  do  not,  we  must  use  opium,  preferably  by 
suppository. 

When  the  patient  wakes  with  the  penis  erect  and  painful,  he 
should  immerse  both  penis  and  testicles  in  a  basin  of  hot  water,  or,  if 
that  is  not  at  hand,  cold  water  will  answer  the  same  purpose,  and  he 
should  also  empty  his  bladder. 

"Breaking  the  chordee"  leads  to  violent  haemorrhage  and  ulti- 
mately to  severe  traumatic  stricture. 


(77) 


EPIDIDYMITIS.  79 

Epididymitis,  or  inflammation  of  the  head  of  the  testicle,  is  not 
a  result  of  metastasis  through  the  blood-vessels  or  lymph-channels, 
but  is  caused  by  the  passage  of  gonococci  from  the  posterior  urethra 
to  the  epididymis  by  way  of  the  seminal  vesicles  and  vas  deferens. 

The  body  of  the  testicle  proper  is  not  involved,  as  a  rule,  and  the 
inflammation  is  limited  to  the  epididymis,  but  the  testicle  is  often 
apparenthj  enlarged  on  account  of  its  being  surrounded  by  the  swollen 
and  inflamed  epididymis.  Another  element  which  causes  the  testicle 
to  appear  larger  than  normal  is  the  effusion  of  serum  which  takes 
place  into  the  sac  of  the  tunica  vaginalis,  and  causes  hydrocele.  This 
may,  in  time,  be  absorbed  or  remain  permanently  and  increase. 

The  symptoms  are  always  well  marked.  There  is  severe  pain  in 
the  testicle,  Radiating  up  into  the  abdomen.  The  patient's  gait  is 
characteristic:  he  bends  over  as  he  stands  and  walks  with  his  legs 
straddling  in  order  to  relax  the  spermatic  cord  and  relieve  it  from 
the  weight  of  the  enlarged  testicle. 

The  purulent  discharge  of  the  gonorrhoea  generally  ceases  at 
once,  and  remains  absent  until  the  inflammation  in  the  epididymis 
is  better,  and  then  the  discharge  begins  again,  only  not  as  profusely 
as  before. 

On  examining  the  testicle  we  find  the  epididymis  enlarged,  hard, 
and  tender,  and  the  testicle  cannot  be  readily  outlined  on  account.- 
of  the  effusion  of  serum  into  the  sac  of  the  tunica  vaginalis.     The 
spermatic  cord  is  thickened  and  very  tender.    The  inflammatory  prod- 
ucts disappear  by  resolution  and  rarely  suppurate. 

If  both  epididymes  have  been  affected,  a  condition  of  sterility 
may  be  left,  which  is  permanent.  The  function  of  the  testicle  may  be 
destroyed  in  three  ways: — 

I.  The  most  common  is  the  formation  of  an  inflammatory  in- 
filtrate in  the  head  of  the  epididymis,  which  is  not  absorbed,  but 
remains  and  forms  a  plug,  blocking  up  the  efferent  duct. 

II.  An  atrophy  of  the  glandular  structure  of  the  testicle  may 
occur,  probably  as  a  result  of  inflammatory  products  in  its  substance. 

III.  In  very  exceptional  cases  the  body  of  the  testicle  suppurates 
and  sloughs  out,  and  in  this  way  the  organ  itself  may  be  entirely 
destroyed. 

Tubercular  disease  of  the  testicle  occasionally  follows  a  gonor- 
rhoea! epididymitis,  and  is  due  to  the  lighting  up  of  a  focus  of  tuber- 
cular material,  which  had  been  unsuspected  and  dormant  in  the  epi- 
flidvmis. 


80 


COMPLICATIONS  OF  ACUTE  GONORRHCEA. 


Treatment. — If  seen  within  the  first  few  hours,  the  severity  of 
the  inflammation  may  be  lessened  by  applying  three  or  four  leeches 
along  the  spermatic  cord.  The  patient  should,  of  course,  be  put  in 
bed  and  the  testicles  supported  by  means  of  a  Curling  handkerchief 
bandage. 

Hot  applications  are  to  be  preferred  rather  than  the  ice-bag,  al- 
though ice  was  at  one  time  very  popular.  While  the  ice  subdues  the 
inflammatory  symptoms  promptly,  its  use  is  very  apt  to  be  followed 
by  a  hard,  tough  infiltration  in  the  epididymis,  which  is  never  ab- 
sorbed, but  remains,  blocking  up  the  epididymis  and  causing  sterility. 
Another  disadvantage  of  ice  is  that  atrophy  of  the  testicle  is  more  apt 
to  occur  in  the  cases  where  it  has  been  used. 

The  hot  applications  can  be  used  in  the  form  of  hot  lead-and- 
opium  wash  or  flaxseed  poultices,  or  a  poultice  made  by  splitting  a 


Fig.  23. — Horand-Langlebert  Suspensory  Bandage. 


paper  of  chewing  tobacco,  dipping  it  in  hot  water  for  a  moment,  and 
then  applying  it  around  the  testicle.  In  this  way  the  nicotine  passes 
into  the  circulation  and  lessens  the  arterial  tension.  In  cases  where 
a  great  deal  of  effusion  has  taken  place  into  the  cavity  of  the  tunica 
vaginalis,  it  is  desirable  to  relieve  the  tension  promptly  by  drawing  off 
the  fluid  with  an  aspirating  needle. 

In  cases  of  epidid3^mitis  which  are  not  very  severe,  the  Horand- 
Langlebert  suspensory  bandage,  lined  with  a  thick  pad  of  cotton- 
batting,  fills  the  indications  of  rest,  warmth,  and  suspension,  and  at  thej 
same  time  permits  the  patient  to  walk  about  without  pain. 

After  the  pain  of  the  acute  inflammation  has  subsided  Finger] 


GONORRHCEAL  RHEUMATISM.  81 

advises  the  constant  use  of  evaporating  lotions,  which  he  believes  are 
a  surer  means  of  causing  the  absorption  of  the  infiltration  in  the 
epididymis  than  any  other,  at  this  particular  stage,  although  later 
massage  is  in  order. 

After  the  patient  is  out  of  bed  and  begins  to  go  about,  the  evapo- 
rating lotions  may  be  discontiniied,  and  pressure  upon  the  testicle  may 
be  applied  by  means  of  firm  bandaging  used  in  addition  to  the  sus- 
pensory bandage. 

Various  other  plans  have  been  used  with  a  view  of  promoting 
absorption  of  the  inflammatory  products.  A  favorite  one  consisted  in 
strapping  the  testicle  with  straps  of  adhesive  plaster,  and  another 
which  is  in  common  use  to-day  consists  in  the  application  of  ointments 
designed  to  stimulate  absorption.  The  one  which  is  most  commonly 
employed  is: — 

R  Ichthyol     3j. 

I.anolin, 

Vaselin    aa  3ss. 

M.     Sig. :    To  be  applied  constantly  on   lint  to  testicle. 

Iodide  of  potash  given  internally  is  of  no  use  in  producing  ab- 
sorption of  the  inflammatory  products. 

The  Paqvelin  cautery  is  sometimes  used  by  brushing  it  lightly 
over  the  surface  of  the  skin  of  the  scrotum  and  burning  or  searing  it 
very  superficially.  In  the  beginning  of  the  disease  it  has  the  effect 
of  allaying  pain,  and  later  on  produces  absorption  of  the  inflamma- 
tory products. 

In  order  to  prevent  sterility  it  is  important  to  promote  the  ab- 
sorption of  the  newly  formed  tissue  in  the  epididymis. 

In  recent  cases  while  the  infiltrate  is  soft  this  may  be  accom- 
plished by  a  sort  of  massage,  or  kneading,  of  the  infiltration  between 
the  thumb  and  finger;  but  in  cases  of  long  standing,  when  the  in- 
filtration has  become  hard  and  dense,  all  such  attempts  are  unsuc- 
cessful. 


Gonorrhoea!  rheumatism  is  an  inflammation  of  one  or  more  joints 
occurring  in  the  course  of  a  gonorrhoea  and  due  to  the  direct  action 
of  the  gonococcus.  The  gonococci  are  carried  through  the  blood- 
current,  and  are  deposited  in  various  joints,  where  they  set  up  an 
inflammation  in  the  synovial  membrane  lining  them. 

If  the  gonococci  alone  are  deposited  in  the  joint,  the  resulting 


83  CO:\IPLICATIONS  OF  ACUTE  GONORRHCEA. 

inflammation  causes  an  excessive  secretion  of  serum,  and  a  simple 
hydrarthrosis  results,  or  the  inflammation  may  attack  the  synovial 
sheaths  of  tendons  and  the  bursas,  occasioning  a  chronic  thickening. 

Suppurative  inflammations  of  the  joint  are  due  to  a  mixed  in- 
fection; in  addition  to  the  gonococci,  staphylococci  and  streptococci 
are  the  exciting  causes. 

Clinically  we  can  distinguish  three  forms  of  gonorrhoeal  rheu- 
matism:— 

(o)  Hydrarthrosis,  which  is  usually  confined  to  a  single  joint 
(monarticular),  and  is  generally  the  knee. 

(&)  Kesembling  ordinary  rheumatism,  since  it  begins  with  fever, 
and  several  joints  are  involved. 

(c)  The  synovial  sheaths  of  tendons  and  muscles  and  the  bursse 
are  attacked  and  become  the  seat  of  chronic  inflammatory  changes. 
The  joints  may  be  involved  or  may  escape. 

The  course  of  all  forms  is  very  slow,  and  recovery  is  always  pro- 
tracted. 

Treatment. — It  is  of  essential  importance  to  treat  the  gonorrhoea, 
which  almost  always  affects  the  posterior  urethra  or  its  adnexa. 

In  the  cases  which  begin  with  active  symptoms — high  fever,  rapid 
pulse,  and  the  affection  of  several  joints — salicylate  of  soda  acts  well, 
but  in  a  case  which  is  insidious  in  its  beginning  and  turns  out  to  be  a 
slow,  chronic  synovitis,  giving  rise  to  a  hydrarthrosis,  the  salicylates 
are  of  little  use. 

Iodide  of  potash  given  in  increasingly  large  doses,  even  as  high 
as  3  or  4  drachms  a  day,  is  sometimes  of  more  benefit  than  anything 
else.    Salol  and  oil  of  gaultheria  are  also  sometimes  of  use. 

The  local  treatment  is  important.  The  inflamed  joint  should  be 
put  at  rest  by  keeping  the  patient  in  bed  and  applying  a  light  splint 
to  immobilize  it.  If  much  heat,  redness,  and  swelling  are  present,  an 
evaporating  lotion  or  an  ice-bag  is  in  order. 

After  the  acute  stage  has  passed  off  the  indications  for  treatment 
are: — 

I.  To  produce  absorption  of  the  watery  effusion  in  the  joint. 

The  most  powerful  agent,  to  this  end,  is  hlistering,  and  it  should 
be  applied  on  different  parts  of  the  skin  over  the  joint,  and  used  often 
enough  to  keep  the  surface  raw  for  a  considerable  length  of  time. 

Ichthj'ol  ointment,  of  50-per-cent.  strength,  is  sometimes  useful 
as  an  absorbent.  In  all  chronic  cases  when  the  patient  walks  about 
pressure  over  the  joint  by  means  of  a  rubber  bandage  should  be  ap 


i 


GONORRHCEAL  RHEUMATISM.  83 

plied,  and  this  may  serve  as  a  substitute  for  blistering  when  the 
amount  of  fluid  is  slight. 

When  in  spite  of  treatment  the  fluid  does  not  disappear,  it  may 
be  necessary  to  aspirate  the  joint,  and  draw  off  the  fluid  and  irrigate 
its  cavity  with  a  solution  of  bichloride  of  mercury,  1  in  5000.  After 
the  efl'usion  of  serum  has  been  removed  the  indication  is: — 

//.  To  cause  absorption  of  the  inflammatory  deposit,  ivliich  has 
talen  place  around  hursce,  tendons,  and  synovial  sheaths. 

This  can  often  be  accomplished  by  massage  and  the  douching  or 
spraying  with  hot  and  cold  water  alternately.  Cases  selected  for  this 
treatment  should  always  be  very  chronic  ones,  as  much  harm  would 
be  done  to  an  active  inflammation  by  attempts  at  passive  motion  or 
massage. 


INFLAMMATIONS  OF  THE  PROSTATE. 


CHAPTER  VIL 

ACUTE  PROSTATITIS.^ 

The  acute  inflammations  of  the  prostate  occur  in  three  well- 
marked  forms: — 

I.  Simple  acute  prostatitis,  or  congestion,  which  accompanies  every 
case  of  posterior  urethritis.  There  is  merely  an  intense  hyperaemia  of 
the  gland,  with  a  distension  of  all  its  blood-vessels.  The  symptoms 
are  not  characteristic,  and  are  only  those  proceeding  from  the  poste- 
rior urethritis. 

On  rectal  examination  the  prostate  is  found  to  be  slightly  en- 
larged, soft,  and  tender  to  the  touch. 

The  treatment  of  this  condition  simply  consists  in  treating  the 
posterior  urethritis. 

II.  The  second  form  of  prostatitis  is  the  acute  follicular  pros- 
tatitis, in  which  one  or  two  prostatic  follicles  become  the  seat  of  an 
inflammation  which  is  localized  to  the  cavities  of  the  glands. 

On  rectal  examination  one  or  two  nodules  are  discernible  in  the 
substance  of  the  prostate,  which  are  hard  and  painful  on  pressure  and 
which  are  the  inflamed  follicles.    This  condition  may  terminate  in: — ■ 

(a)  Suppuration,  in  which  the  inflammatory  material  in  the  fol- 
licles suppurates,  and  breaks  out  into  the  urethra,  leaving  a  small 
fistulous  opening  which,  in  the  course  of  time,  closes  by  granulation. 

[h)  Resolution,  in  which  the  inflammatory  products  disappear  by 
a  process  of  absorption. 

III.  Parenchymatous  prostatitis,  in  which  the  whole  substance  of 
the  gland  is  involved  in  an  inflammatory  process.  This  condition  may 
occur  as  the  result  of  acute  congestion  or  follicular  prostatitis,  or  may 
develop  independently  in  the  course  of  a  gonorrhoea. 


'  In  the  consideration  of  the  acute  and  chronic  forms  of  prostatitis  no 
reference  will  be  made  to  the  senile  hypertrophy  of  the  prostate,  which  occurs 
in  old  men  and  which  is  considered  later  in  a  separate  section. 
(84) 


I 


ACUTE  PROSTATITIS.  85 

The  congestion  and  swelling  of  the  gland  reaches  its  height  about 
the  seventh  day,  and  may  terminate  in  either:  (a)  resolution;  (&)  sup- 
puration;   (c)  induration. 

SYMPTOMS. 

The  symptoms  of  parenchymatous  prostatitis  are  well  marked. 
The  patient  has  a  good  deal  of  fever,  and  complains  of  pain  in  the 
perineum  and  rectum,  which  is  increased  by  pressure.  There  is  a  con- 
stant feeling  as  though  a  foreign  body  were  in  the  rectum,  which 
occasions  expulsive  efforts  on  the  part  of  the  muscles  and  causes  rectal 
tenesmus. 

If  the  enlargement  of  the  prostate  is  considerable,  it  bulges  into 
the  rectum,  and  after  defecation  the  stools  are  flat  and  ribbon  shaped. 
If  the  prostate  is  enlarged  anteriorly,  it  presses  upon  the  urethra  and 
causes  difficulty  in  micturition  or  complete  retention  of  urine. 


COTJRSE  AND  TEEMINATIONS  OF  PARENCHYMATOUS  PROSTATITIS. 

In  the  cases  which  undergo  resolution  there  is  a  gradual  improve- 
ment in  the  symptoms.  On  the  other  hand,  if  suppuration  takes 
place,  an  abscess  forms  in  the  centre  of  the  gland,  and  the  formation 
of  pus  is  announced  by  a  throbbing  pain  in  the  perineum  and  chills, 
followed  by  fever  and  sweating.  If  operative  measures  are  not  resorted 
to,  the  pus  bursts  through  the  capsule  of  the  prostate  and  the  abscess 
empties  itself  into  (a)  the  urethra,  {h)  the  rectum,  (c)  or  through  the 
perineum,  {d)  or  may  take  an  eccentric  course. 

The  pus  has  been  known  to  burrow  its  way  through  the  abdom- 
inal cavity  and  finally  empty  through  the  inguinal  region,  the  um- 
bilicus, the  sciatic  foramen,  at  the  edge  of  the  false  ribs,  through  the 
space  of  Eetzius,  etc. 

In  favorable  cases  the  fistulous  opening  may  close  by  granulation, 
but  fjeces,  urine,  or  pyogenic  germs  may  easily  enter  the  fistula,  and 
urinary  infiltration,  septic  infection,  and  pyaemia  are  not  infrequent 
results.  A  perforation  into  the  rectum  or  urethra  may  leave  a  perma- 
nent fistulous  opening,  with  its  attendant  annoyances. 

In  statistics  collected  by  Segond,  in  ll-l  cases  recovery  occurred 
in  70  and  death  in  34.  The  third  termination  of  induration  is  rarer 
than  the  two  preceding.  Suppuration  does  not  occur,  and  the  conges- 
tion subsides,  but  the  gland  is  left  in  a  condition  of  enlargement  and 
fibrous  hardening,  which  remains  permanent. 


8(3  INFLAMMATIONS  OF  THE  PROSTATE. 

DIAGNOSIS. 

Parenchymatous  prostatitis  may  readily  be  overlooked,  and  the 
case  regarded  as  one  of  posterior  urethritis,  which  is  always  present 
and  has  similar  symptoms,  unless  rectal  examination  is  made,  by  which 
the  enlargement  of  the  prostate  can  be  easily  felt. 


TREATMENT. 

The  indications  are: — 

I.  To  prevent  suppuration  of  the  gland. 

II.  To  lessen  the  severity  of  the  posterior  urethritis. 

The  patient  is  put  to  bed,  sandal-wood  oil  is  administered,  and 
the  pain  and  tenesmus  controlled  by  opium.  Locally  either  an  ice- 
bag  or  hot  poultices  are  applied  to  the  perineum,  a  safe  guide  for 
the  choice  between  hot  and  cold  applications  being  the  sensation  of 
comfort  afforded  to  the  patient. 

Continuous  irrigation  of  the  rectum  with  hot  water,  for  half  an 
hour  at  a  time,  by  means  of  Kemp's  tube  is  often  useful. 

If  retention  of  urine  should  occur,  the  catheter  must  be  intro- 
duced, but  only  when  absolutely  necessary,  and  before  catheterizing 
the  urethra  should  be  well  irrigated  to  free  it  from  pus,  which  might 
be  pushed  ahead  of  the  catheter  into  the  bladder. 

If  great  dii^iculty  is  experienced  in  introducing  the  catheter,  it  is 
proper  to  anaesthetize  the  patient  with  ether  and  leave  the  catheter 
tied  in  the  bladder,  to  obviate  the  difficulty  of  reintroduction.  In 
extreme  cases  aspiration  of  the  bladder  above  the  pubes  may  be  de- 
manded. 

As  soon  as  pus  forms,  the  abscess  should  be  immediately  evacu- 
ated, in  order  to  prevent  the  pus  from  bursting  through  the  capsule 
of  the  gland,  burrowing  into  the  tissues,  and  causing  urinary  infiltra- 
tion and  pyaemia  or  at  least  a  fistula  which  is  slow  in  healing. 

Technique  of  Operation. — The  patient  is  anyssthetized  and  a  sound 
introduced  through  the  urethra  into  the  bladder.  A  semilunar  in- 
cision is  made  through  the  skin  of  the  perineum,  curving  around  the  J 
rectum  in  order  to  avoid  wounding  it.  The  incision  is  deepened  byj 
dissection  until  the  capsule  of  the  gland  is  reached  and  opened  and] 
the  pus  evacuated.  The  wound  is  packed  and  allowed  to  heal  by] 
granulation. 

Another  procedure  which  is  only  applicable  to  those  cases  where! 
operation  has  been  delayed  and  the  abscess  is  seen  obviously  pointing 


CHRONIC  PROSTATITIS.  •  87 

in  the  perineum  is,  with  the  finger  in  the  rectum,  as  a  guide,  to  thrust 
a  narrow  straiglit  bistoury  directly  into  the  fluctuating  mass,  through 
the  skin  of  the  perineum,  and  evacuate  the  pus. 


CHRONIC  PROSTATITIS. 

Chronic  inflammation  of  the  prostate  may  originate  as  the  result 
of  an  acute  attack  of  prostatitis,  particularly  the  follicular  form.  It 
may  also  occur  from  the  extension  of  a  chronic  inflammation  from 
the  posterior  urethra,  which  was  either  gonorrhoeal  in  origin  or  due 
to  the  chronic  congestion  and  inflammation  brought  about  by  sexual 
excesses  or  abuses. 

PATHOLOGICAL  ANATOMY. 

On  examination  the  prostate  is  found  to  be  enlarged  and  soft. 
The  crypts  and  follicles  are  always  attacked  by  catarrhal  inflammation, 
the  cavities  of  the  glands  often  contain  pus,  and  the  openings  of  their 
ducts  are  always  large  and  patulous. 

SYMPTOMS. 

As  chronic  prostatitis  is  always  complicated  by  chronic  posterior 
urethritis,  the  symptoms  will  arise  from  both  conditions,  and  are  as 
follow: — 

(a)  Frequent  and  urgent  urination. 

(h)  Partial  or  complete  impotence. 

(c)  Mental  symptoms,  which  are  grouped  under  the  general  term 
'•'sexual  neurasthenia,"  and  consist  of  hypochondria,  irritability  of  tem- 
per, depression  of  spirits,  inability  for  prolonged  mental  effort,  forget- 
fulness,  etc. 

The  only  symptom  which  points  directly  to  the  involvement  of 
the  follicles  of  the  prostate  is 

(d)  Prostatorrhcea,  which  is  the  term  given  to  the  discharge  of 
sticky,  glairy  mucus  from  the  meatus  after  stool  and  after  urination. 
It  is  due  to  the  contractions  of  the  muscles  about  the  base  of  the  blad- 
der and  rectum,  pressing  upon  the  prostate  and  squeezing  out  the 
contents  of  the  prostatic  crypts  and  follicles  through  their  dilated 
ducts. 


88  INFLAMMATIONS  OF  THE  PROSTATE. 

DIAGNOSIS. 

As  the  clinical  history  of  chronic  prostatitis,  seminal  vesiculitis, 
and  chronic  posterior  urethritis  is  similar,  we  can  only  make  a  dif- 
ferential diagnosis  by  a  careful  examination  of  the  patient. 

On  passing  a  hulbous  hougie  into  the  posterior  urethra  extreme 
tenderness  is  felt  by  the  patient.  The  endoscope  shows  the  mucous 
membrane  of  the  posterior  urethra  to  be  of  a  deep  purple  or  violet 
color,  bleeding  slightly  on  introducing  the  tube,  and  covered  possibly 
with  granulations. 

After  washing  out  the  anterior  urethra,  if  the  patient  passes  his 
urine  in  a  glass  pus  may  be  present  or  not,  and,  at  the  end  of  the 
act  of  urination,  Fuerbringer's  booklets,  which  have  been  squeezed 
out  from  the  prostatic  crypts,  will  appear  floating  in  the  glass  as 
comma-  or  tadpole-  shaped  bodies. 

The  expression-urine  test,  which  is  made  by  stripping  or  express- 
ing the  contents  of  the  prostate  into  the  urethra,  by  massage  through 
the  rectum,  is  an  important  means  of  diagnosis,  as  we  can  in  this  way 
get  the  prostatic  secretion  for  microscopic  examination,  and  at  the 
same  time  judge  of  the  size  and  consistency  of  the  prostate  itself  by 
the  touch. 

Boettscher's  crystals  are  usually  found  on  microscopic  examina- 
tion in  the  material  expressed  from  the  prostate,  upon  adding  a  drop 
of  l-per-cent.  solution  of  acid  phosphate  of  ammonia  to  it. 

The  crystals  are  distinguished  by  their  dagger  shape  and  the  beau- 
tiful forms  which  they  assume  upon  crystallization.  These  crystals 
only  form  in  prostatic  fluid,  as  their  base  does  not  exist  elsewhere. 

TREATMENT. 

It  is  important,  in  the  treatment  of  these  cases,  to  secure  the  con- 
fidence of  the  patient  and  encourage  him  by  explaining  that  his  con- 
dition is  one  which  can  be  cured,  and  that  he  is  not  impotent  nor 
likely  to  become  so,  and  that  the  mental  disturbances  of  which  he 
complains  are  due  to  a  purely  local  condition  which  is  not  dangerous. 

The  first  indication  for  treatment  is  to  improve  the  general  con- 
dition of  the  patient  by  means  of  diet  and  exercise  in  the  open  air. 

Constipation  is  generally  a  prominent  symptom,  and  it  is  neces- 
sary to  regulate  the  bowels,  using  saline  cathartics  for  their  depleting 
action  on  the  pelvic  organs,  which  has  some  effect  in  relieving  the 
congestion  of  the  prostate. 

Of  course,  all  sources  of  erotic  excitement  should  be  interdicted 


CHRONIC  PROSTATITIS.  89 

on  account  of  their  effect  in  inducing  congestion  of  the  prostate.  Un- 
der the  head  of  local  treatment  we  can  speak  of  measures  which  have 
a  more  direct  action  upon  the  prostate  itself. 

Sitz-baths  of  hot  salt-water  of  from  ten  to  fifteen  minutes'  dura- 
tion have  an  effect  in  improving  the  condition  of  the  diseased  organ. 
Irrigation  of  the  rectum  with  a  Kemp  tube,  with  either  hot  or  cold 
water,  is  often  beneficial. 

The  most  useful  means  of  affecting  the  prostate  itself  is  massage 
through  the  rectum.  We  can  in  this  way  express  the  contents  of  the 
glands,  and  after  the  patient  has  urinated,  if  an  irrigation  is  used,  the 
fluid  will  penetrate  into  the  previously  emptied  crypts  and  follicles. 

It  is  important  at  the  same  time  not  to  overlook  the  posterior 
urethritis,  but  to  cure  that  as  well. 

If  there  is  a  great  deal  of  catarrhal  inflammation,  with  much 
pus-formation,  irrigations  are  in  order;  but,  if  the  suppuration  is  only 
slight,  instillations  with  an  Ultzmann  syringe  are  indicated.  The 
endoscope  is  useful  in  a  small  number  of  cases  when  granulations  are 
present  or  when  it  is  necessary  to  make  a  strong -application  to  the 
verumontanum. 

Sounds  should  be  used  cautiously  and  as  a  last  resource,  and  we 
should  be  sure  that  all  acute  inflammatory  symptoms  have  subsided, 


Fig.  24. — Benique  Sound. 

since  epididymitis,  vesiculitis,  etc.,  can  readily  be  induced  by  their 
reckless  use. 

The  Benique  sound  is  particularly  useful  here,  since  it  does  not 
tear  or  lacerate  the  tissues,  and,  from  its  shape  and  weight,  it  exer- 
cises a  certain  amount  of  compression,  which  is  a  stimulant  to  the 
process  of  absorption. 

The  psychrophor,  or  cooling  sound,  is  a  hollow  sound  which  allows 
a  stream  of  water  to  flow  through  it,  in  order  to  keep  it  cold  as  it  lies 
in  the  urethra.    It  is  made  in  the  form  of  an  ordinary  steel  sound,  but 


90  ixflamjVIatioxs  of  the  prostate. 

is  more  useful  if  made  with  the  Benique  curve.  The  psychrophor  com- 
bines the  eilects  of  pressure  and  cold,  and  is  often  very  valuable  when 
prostatorrhcea  is  the  chief  symptom  and  occasioned  by  a  relaxation  of 
the  mouths  of  the  glands.  It  should  be  used  every  day  or  second  day 
for  from  fifteen  to  thirty  minutes  at  a  time. 

PROGNOSIS. 

The  prognosis  of  chronic  prostatitis  is,  on  the  whole,  not  un- 
favorable, but  improvement  is  slow,  and  treatment  must  be  continued 
for  a  long  time.  Improvement  can  be  readily  noted  by  feeling  the 
decrease  in  size  of  the  prostate  through  the  rectum,  and  after  a  short 
time  under  treatment  the  mental  symptoms  of  the  patient  undergo  a 
marked  change  for  the  better. 

Relapses  are  apt  to  occur  from  a  lighting  up  of  the  catarrhal  in- 
flammation and  must  be  treated  by  suspending  all  local  treatment  with 
soimds  and  relying  on  irrigations  or  instillations  of  nitrate  of  silver 
into  the  posterior  urethra. 


DISEASES  OF  THE  SEMINAL  VESICLES. 


CHAPTER  VIIL 

ACUTE  SEMINAL  VESICULITIS. 

Acute  inflammations  of  the  seminal  vesicles  are  generally  dne  to 
gonorrhoea,  although  a  chronic  inflammation  may  originate  from  other 
causes. 

A  gonorrhoeal  inflammation  of  the  interior  of  the  cavity  of  the 
vesicle  is  excited  when  the  gonococci  pass  from  the  posterior  urethra 
through  the  ejaculatory  ducts,  and  are  deposited  within  the  vesicle. 

Its  walls  secrete  pus  and  its  cavity  soon  becomes  filled  up  and 
distended  with  a  purulent  accumulation. 


SYMPTOMS. 

The  symptoms  are  not  very  characteristic,  and  are  merely  those 
of  the  posterior  urethritis,  which,  of  course,  is  always  present.  Fever 
and  a  throbbing  pain  in  the  vesicles  and  tenderness  in  the  suprapubic 
region  are  always  observed. 

Seminal  discharges  which  are  red  or  chocolate  colored  from  the  ad- 
mixture with  blood  often  occur.  The  blood  may  be  derived  from  the 
cavity  of  the  vesicle  itself  or  may  be  acquired  by  the  semen,  from  a 
congested  posterior  urethra,  as  it  passes  through  it. 

If  the  posterior  urethritis  is  cured,  the  urine  is  clear  at  first,  but 
later  in  the  disease  the  vesicles  pour  out  their  purulent  contents  into 
the  posterior  urethra  and  the  pus  flows  back  into  the  bladder,  dis- 
coloring the  urine  when  it  is  passed. 


DIAGNOSIS. 

The  diagnosis  of  seminal  vesiculitis  can  only  be  made  by  rectal 
examination,  and  the  vesicles  can  be  felt  swollen,  soft,  fluctuating, 
and  intensely  tender. 

Epididymitis  is  a  most  frequent  result  of  vesiculitis,  and  is 
brought  about  by  some  of  the  gonococci-laden  pus-cells  being  carried 
through  the  vas  deferens  and  deposited  in  the  epididvmis. 

(91) 


92  DISEASES  OF  THE  SEMINAL  VESICLES. 

Peritonitis,  which  sometimes  becomes  general,  may  occur  from 
the  close  relation  which  the  peritoneum  bears  to  the  vesicles. 

TREATMENT. 

The  treatment  of  acute  vesiculitis  is  chiefly  expectant,  and  con- 
sists in  putting  the  patient  to  bed  and  giving  a  saline  cathartic,  which 
is  always  in  order  in  every  pelvic  inflammation. 

Hot  sitz-baths  and  copious  irrigations  of  the  rectum  with  hot 
water  are  useful  in  allaying  the  inflammation. 

If  the  posterior  urethritis  is  severe,  sandal-wood  oil  relieves  the 
tenesmus  and  renders  the  urine  less  irritating. 

Injections  into  the  anterior  urethra,  of  course,  are  contra-indi- 
cated, but  above  all  things  any  attempt  at  massage  or  stripping  the 
vesicles  should  be  absolutely  interdicted. 

Under  this  plan  of  treatment  most  cases  of  acute  vesiculitis  will 
get  well  in  from  two  to  four  weeks'  time;  but  when  resolution  does 
not  occur  the  disease  passes  into  the  chronic  state. 


CHRONIC  SEMINAL  VESICULITIS. 

The  condition  of  chronic  inflammation  of  the  seminal  vesicles  was 
but  little  understood  until  the  publication  of  Eugene  Fuller's  first 
paper  upon  this  subject  in  1893.  Chronic  vesiculitis  may  originate 
from  an  acute  attack  of  vesiculitis  which  does  not  undergo  resolution; 
but,  as  a  rule,  it  develops  insidiously,  as  the  result  of  the  extension 
of  a  chronic  inflammatory  process  which  begins  in  the  posterior  ure- 
thra and  extends  through  the  ejaculatory  duct.  The  ejaculatory  duct 
is  never  compressed  by  the  changes,  but  throughout  the  whole  course 
of  the  disease  it  remains  patulous,  and  sterility  does  not  occur. 

According  to  the  classification  devised  by  Fuller,  chronic  seminal 
vesiculitis  presents  itself  in  two  varieties: — 

I.  Atonic  vesiculitis,  in  which  there  is  only  an  atony  of  the  mus- 
cular fibres  composing  the  walls  of  the  vesicle. 

II.  Inflammatory  vesiculitis,  in  which  the  walls  of  the"  vesicles 
are  thickened  and  indurated  as  a  result  of  inflammation,  which  may 
be  simple,  gonorrhoeal,  or  tubercular  in  origin. 

Either  form  of  vesiculitis  may  exist  by  itself;  but,  as  a  rule, 
there  is  a  combination  of  atony  and  inflammation  of  the  vesicular 
walls. 


D'SsecT^Dtc  DJfstvMOvT: 


Af /v-'/v/jZ     Wfi  ic  i-'eit 


Fig.  25. — Diaj!:ram  of  the  Seminal  Vesicles.    The  Right  Vesicle  has  been 
Dissected,  and  its  Convolutions  Drawn  Out  Straight. 


E,  Ureter. 

F,  Vas  Deferens. 

G,  Seminal  Vesicle. 
E,  Base  of  Bladder. 
1,  Ejaculatory  Duct. 


J,  Crus  Penis. 

K,  Corpus  Cavernosum. 

h.  Bulbous  Urethra. 

J/,  Membranous  Urethra. 

2V,  Prostate. 


0,  Ureter. 


(93) 


CHRONIC  SEMINAL  VESICULITIS. 


95 


Atonic  Vesiculitis. 
This  form  of  vesiculitis  may  be  induced  by  a  previous  attack  of 
acute  inflammation  in  the  organ,  which  does  not  undergo  complete 
resolution.  It  is  more  liable,  however,  to  be  provoked  by  some  form 
of  sexual  abuse,  which  consists  in  a  frequent  repetition  of  the  sexual 
act.  In  consequence  the  muscular  fibres  become  exhausted,  lose  their 
tone,  and  the  walls  of  the  vesicles  become  thinned,  atonied,  and 
stretched.  The  cavities  become  distended  with  seminal  fluid,  because 
the  weakened  muscular  fibres  are  no  longer  able  to  evacuate  the  con- 
tents, and  the  secretion  becomes  thick  and  inspissated. 


Fig.  26. — Microscopic  examination  of  material  expressed  from 
Seminal  Vesicles  and  Prostate,  showing  Spermatozoa,  Pus-cells,  and 
Boettscher's  Crystals. 


The  vesicles  are  distended  and  enlarged,  and  feel  like  a  swollen 
leech  to  the  examining  finger. 

On  stripping  the  vesicles  the  expressed  seminal  fluid  appears  ab- 
normal. 

The  expression  urine  is  not  clear  or  slightly  milky  in  color  as  it 
should  be,  but  the  expressed  contents  of  the  vesicles  appear  in  the 
glass  of  urine  as  coagulated  masses  of  gelatinous  materiuv,  which  often 


96  DISEASES  OF  THE  SEMINAL  VESICLES. 

resemble  casts  half  an  inch  long  and  as  thick  as  a  knitting-needle. 
These  masses  are  the  jellified  contents  of  the  vesicle,  molded  by  the 
ejaculatory  ducts,  as  they  are  squeezed  through  them. 

The  other  form  in  which  the  inspissated  semen  is  found  resembles 
sago-like  globules  floating  in  the  urine. 

After  a  time  the  atonic  vesicle  almost  invariably  becomes  infected 
by  some  germ,  often  the  bacillus  coli  from  the  rectum,  and  inflam- 
matory changes  are  induced. 

For  practical  purposes  it  is  only  necessary  to  consider  two  forms 
of  chronic  inflammation  of  the  vesicle:— 

(a)  Chronic  inflammation  without  perivesiculitis. 

(b)  Chronic  inflammation  with  perivesiculitis. 

When  perivesiculitis  is  absent,  there  is  no  inflammatory  infiltra- 
tion or  hyperplasia  of  the  connective  tissue  surrounding  the  vesicles. 
The  vesicle  is  large,  and  its  walls  are  thinned  and  atonied,  but  they 
are  hardened  and  sclerosed  by  fibrous  changes,  as  a  result  of  the  in- 
flammation which  always  occurs  in  this  form  within  the  walls. 

A  muco-purulent  secretion  may  be  abundant  and  accumulate 
within  the  cavity  of  the  vesicle.  Granulations  often  form  within  the 
cavity,  causing  haemorrhage. 

The  entire  vesicle  may  be  filled  with  a  blood-clot,  or,  if  the  bleed- 
ing is  slight,  the  seminal  discharges  may  be  stained  brown  or  chocolate 
color. 

When  perivesiculitis  is  present,  a  small  round-celled  infiltration 
is  thrown  out  in  the  early  stages,  surrounding  and  imbedding  the 
vesicles.  In  time  the  infiltration  becomes  organized  with  fibrous  con- 
nective tissue,  which  forms  adhesions,  binding  the  vesicles  down  to 
the  base  of  the  bladder.  The  entire  mass,  composed  of  vesicles  im- 
bedded in  fibrous  tissue,  appears  like  a  part  of  the  prostate,  and  may 
easily  be  mistaken  for  it,  on  rectal  examination. 

After  the  fibrous  tissue  has  existed  for  a  little  time,  it  begins  to 
contract  and  in  consequence  the  vesicles  are  pressed  upon  and  squeezed 
together  so  that  they  become  smaller  than  normal. 

The  ejaculatory  duct  is-  never  compressed  by  these  changes,  but 
always  remains  open;  consequently  there  is  no  sterility. 

ETIOLOGY. 

As  to  the  etiology  of  the  inflammatory  forms  of  vesiculitis,  gonor- 
rhoeal  infection  is  a  very  frequent  cause. 

Chronic  vesiculitis  may  originate  from  an  acute  attack  of  vesicu- 


CHRONIC  SEMINAL  VESICULITIS.  97 

litis;  but  it  is  more  frequently  due  to  a  gonorrhceal  intlammation  of 
the  posterior  urethra,  which  extends  along  the  ejaculatory  duct  and 
attacks  the  walls  of  the  vesicle  and  often  the  perivesicular  connective 
tissue. 

Other  causes  besides  gonorrhoea  may  induce  chronic  inflamma- 
tory changes  in  and  around  the  vesical  walls. 

A  non-specific  vesiculitis,  so  called  to  distinguish  it  from  the  gon- 
orrhoea!, or  specific,  form,  may  arise  within  the  cavity  of  the  vesicle 
itself,  as  a  result  of  an  atonic  condition  of  the  vesicle. 

Again,  a  low  grade  of  chronic  inflammation  of  the  posterior 
urethra  may  be  established  as  a  result  of  sexual  excesses,  masturba- 
tion, etc.,  which  spreads  along  the  ejaculatory  duct  and  attacks  the 
vesical  wall. 

Finally,  with  old  men  who  are  beginning  catheter  life  the  trau- 
matism often  excites  a  subacute  inflammation  of  the  vesicles,  which 
extends  to  the  epididymis. 

SYMPTOMS. 

The  symptoms  of  both  gonorrhceal  and  simple  vesiculitis  depend 
chiefly  upon  the  accompanying  posterior  urethritis,  and  consist  in 
frequent  urination  and  spasm  or  irritability  of  the  cut-off  muscle.  On 
straining  at  stool  a  glairy,  sticky  discharge  escapes  from  the  meatus, 
which  is  the  secretion  expressed  from  the  prostatic  crypts  by  the  mus- 
cular efforts,  and  is  termed  prostatorrhcea. 

The  menial  symptoms  are  always  very  prominent,  and  the  indi- 
vidual suffers  from  depression  of  spirits  and  melancholy,  irritability 
of  temper,  and  quarrelsomeness.  Hypochondria  is  notably  marked, 
and  patients  are  alarmed  over  ridiculous  trifles.  They  complain  of 
the  penis  being  shriveled,  cold,  or  numb;  that  the  testicles  are  re- 
tracted or  that  one  hangs  lower  than  the  other;  and  suppose  that  the 
testicles  are  beginning  to  atrophy  and  they  are  gi'owing  impotent.  In 
their  alarm  they  consult  some  of  the  advertising  quacks,  who  prey 
upon  their  fears  and  deluded  ignorance. 

Another  important  group  of  symptoms  is  connected  with  the 
sexual  function.  In  the  early  stages  there  is  an  increase  in  the  sexual 
desire,  with  frequent  nocturnal  emissions  and  premature  ejaculation 
on  coitus.  The  seminal  discharges  are  often  mixed  with  blood,  which 
may  be  acquired  from  the  posterior  urethra  or  the  cavity  of  the  ves- 
icles. As  the  case  progresses,  erections  cease,  the  sexual  desire  is  lost, 
and  at  last  a  condition  of  true  impotence  is  established. 


98  DISEASES  OF  THE  SEMINAL  VESICLES. 

DIAGNOSIS. 

The  clinical  history  of  these  cases  is  generally  significant  of  in- 
volvement of  the  vesicles,  in  the  gonorrhoeal  form.  The  patient  com- 
plains of  a  gonorrhoeal  discharge,  which  lasts,  with  intermissions,  for 
years.  Any  slight  indiscretion  brings  on  an  exacerbation,  which  is 
often  mistaken  for  a  fresh  attack  of  gonorrhoea.  The  discharge  lasts 
for  a  few  days  and  then  subsides,  until  another  indiscretion  lights  it 
up  again. 

The  diagnosis  can  only  be  made  by  rectal  examination,  and  in 
order  to  determine  the  condition  of  the  vesicles  a  very  considerable 
amount  of  practice  is  necessary  in  order  to  attain  the  necessary  tadus 
eruditus.  As  the  vesicles  and  prostate  are  continuous,  without  a  line 
of  demarcation,  when  the  perivesiculitis  is  present,  it  is  difficult  for 
the  beginner  to  differentiate  them,  and,  until  one  is  experienced,  a 
diagnosis  of  enlargement  of  the  prostate  is  generally  made,  when  the 
vesicles  alone  are  enlarged  and  the  prostate  is  normal  in  size. 

Technique  of  Examinaiion. — The  patient,  with  his  bladder  mod- 
erately distended  with  urine,  assumes  the  "leap-frog"  attitude,  bend- 
ing over  a  chair  and  grasping  the  sides  with  the  hands.  The  surgeon 
makes  counter-pressure  with  one  fist  doubled  up,  pressing  against  the 
bladder,  and  the  index  finger  of  the  other  hand  is  inserted  into  the 
rectum.  In  order  to  get  well  up  beyond  the  upper  margin  of  the 
vesicle,  it  is  necessary  for  the  surgeon  to  support  his  right  foot  on  a 
chair  and  by  means  of  his  knee  make  strong  pressure  against  the  elbow 
of  his  examining  hand,  in  order  to  drive  it  well  in. 

If  the  vesicles  are  normal,  they  feel  soft,  and  the  amount  of  dis- 
tension depends  on  circumstances.  If  atonic  vesiculitis  is  present,  they 
feel  large,  distended,  tense,  and  very  painful.  If  perivesiculitis  exists, 
they  are  hard,  indurated,  and  brawny,  feeling  like  a  piece  of  pork,  on 
account  of  the  infiltration  through  the  connective  tissue,  which  sur- 
rounds the  vesicles  and  forms  adhesions  which  bind  them  down  upon 
the  bladder. 

After  examining  the  condition  of  the  vesicles  their  contents 
should  be  stripped  or  expressed  by  the  examining  finger,  beginning 
at  the  upper  margin  and  squeezing  or  stroking  in  a  downward  direc- 
tion, so  as  to  press  out  the  contents  through  the  ejaculatory  duct. 
The  quantity  of  expressed  material  which  runs  out  at  the  meatus 
varies  from  a  few  drops  to  half  a  drachm  or  more.  On  examination 
the  material  is  found  to  be  thick  and  jellied  or  purulent,  and  the 


TUBERCULOUS  VESICULITIS.  99 

spermatozoa  are  dead.    As  the  case  improyes,  the  spermatozoa  regain 
life  and  motion. 

TREATMENT. 

The  treatment  consists  in  stripping  or  expressing  the  contents  of 
the  vesicles  once  in  from  tive  to  seven  days.  The  effects  of  stripping 
are  to  empty  the  vesicles  of  their  inspissated  contents,  without  forcing 
the  muscular  fibres  to  contract,  and  eject  the  semen,  and  through  the 
rest  thus  afforded  them  the  muscles  recover  their  tone.  The  inflam- 
matory thickening  around  the  vesicle  is  absorbed  as  a  result  of  the 
massage. 

Contra-indications  to  stripping  are  (a)  the  existence  of  an  acute 
attack  of  vesiculitis,  (&)  blood  in  the  expressed  material,  (c)  or  excess- 
ive tenderness.  "With  these  conditions  present  there  is  always  danger 
of  setting  up  an  epididymitis. 

The  posterior  urethra  should  not  be  overlooked,  but  should  re- 
ceive appropriate  treatment,  with  irrigations  or  instillations  or  by  the 
endoscope.  It  is  desirable,  however,  not  to  use  local  treatment  to  the 
posterior  urethra  and  strip  the  vesicles  at  the  same  sitting,  but  to  allow 
a  couple  of  days  to  intervene.  The  duration  of  treatment  is  protracted, 
requiring  from  two  to  twelve  months  to  effect  a  cure;  but  since  Fuller's 
work  upon  the  subject  it  is  possible  to  cure  cases  which  were  beyond 
the  reach  of  treatment  before. 


TUBERCULOUS  VESICULITIS. 

The  seminal  vesicles  are  usually  involved  by  an  infiltration  with 
tuberculous  nodules  during  the  progress  of  a  case  of  genito-urinary 
tuberculosis. 

The  infection  may  extend  from  tuberculous  deposits  in  the  poste- 
rior urethra  or  prostate  or  may  result  in  consequence  of  an  extension 
of  the  disease  from  the  epididymis  along  the  vas  deferens. 

It  is  supposed  that  the  involvement  of  the  vesicles  in  the  majority 
of  cases  is  secondary,  although  J.  W.  White  has  noted  that  the  vesicles 
often  show  evidences  of  infection  weeks  or  months  before  the  tuber- 
culous process  is  evident  in  the  corresponding  epididymis. 

A  chronic  or  subacute  inflammation  of  the  vesicle,  either  gonor- 


100  DISEASES  OF  THE  SEMINAL  VESICLES. 

rhoeal  or  simple,  is  a  strong  predisposing  element  in  allowing  the 
tubercular  process  to  become  ingrafted  upon  these  organs. 

Uncomplicated  tuberculous  disease  of  the  vesicles  is  never  acute 
except  in  the  presence  of  a  mixed  infection,  either  with  the  gono- 
coccus  or  staphylococcus. 

In  this  case  an  acute  suppurative  inflammation  takes  place  within 
the  cavity  of  the  vesicle,  wdiich  becomes  filled  and  distended  with  pus. 

Uncomplicated  tuberculosis  begins  insidiously,  and  has  a  notable 
tendency  to  invade  the  surrounding  tissues,  and  the  process  often  be- 
comes quiescent,  although  liable  to  take  on  renewed  activity  upon 
slight  provocation. 

A  few  cases,  however,  result  in  breaking  down  of  the  tuberculous 
nodules,  with  the  formation  of  a  perivesicular  abscess,  which  dis- 
charges, either  through  the  rectum  or  perineum,  leaving  a  fistula. 

The  symptoms  of  tuberculosis  of  the  vesicle  are  not  marked,  and 
this  condition  exists  unsuspected  until  a  rectal  examination  is  made, 
disclosing  hard  nodules  in  the  walls  and  perivesicular  connective  tissue. 

As  both  vesicles  are  infiltrated  and  thickened  as  well  as  the 
connective  tissue  around  them,  the  mass  is  continuous  with  the  pros- 
tate, and  it  is  no  easy  task  to  distinguish  these  structures  apart.  In 
advanced  cases  the  prostate  is  almost  always  the  seat  of  tuberculous 
deposits  as  well. 

TREATMENT. 

The  treatment  consists  in  hygienic  measures  alone,  of  which  the 
most  important  is  an  ovit-door  life  in  a  suitable  climate.  Codliver-oil 
and  creasote  are  the  drugs  most  in  vogue. 

Operative  treatment  is,  in  general,  not  required  in  acute  sup- 
purative inflammation  caused  by  a  mixed  infection,  when  the  accu- 
mulation of  pus  takes  place  within  the  cavity  of  the  vesicle,  as  the  pus 
drains  out  into  the  urethra,  through  the  ejaculatory  duct. 

When,  however,  the  perivesicular  tissue  infiltrated  with  tuber- 
cular nodules  breaks  down  and  forms  an  abscess,  it  is  necessary  to 
evacuate  the  pus.  This  may  be  accomplished  through  a  free  incision 
in  the  perineum,  or,  as  Fuller  and  Routier  prefer,  by  thrusting  a  di- 
rector into  the  tumefaction,  through  the  rectum,  and  divulsing  the 
tissues  until  an  opening  large  enough  to  admit  the  finger  is  obtained. 

Extirpation  of  the  vesicle  has  been  attempted  a  few  times  for 
tuberculosis,  but  the  resiilts  are  far  from  satisfactory. 

From  the  inaccessible  location  of  the  vesicles,  an  extensive  in- 


TUBERCULOUS  VESICULITIS.  101 

cision  is  required  to  reach  them,  and  the  haemorrhage  is  difficult  to 
control. 

The  bladder-walls  and  prostate  are  generally  affected,  and  it  is 
difficult  or  impossible  to  remove  all  the  diseased  material.  The  wound 
is  slow  in  healing,  and  the  confinement  to  bed  exerts  a  bad  influence 
upon  the  general  condition  of  the  patient;  so  that  the  tuberculous 
deposits,  which  are  usually  present  elsewhere,  advance  in  consequence. 


STRICTURE  OF  THE  URETHRA, 


CHAPTER   IX. 


SPASMODIC  STRICTURE. 


Spasmodic  stricture  is  a  pure  functional  disturbance,  without 
organic  change,  consisting  in  a  spasm  or  cramp-like  contraction  of 
the  cut-off  muscle  surrounding  the  membranous  urethra. 


CAUSES. 

(a)  Located  in  the  posterior  urethra.  An  abnormal  irritability 
from  excess  in  coitus  or  masturbation. 

(&)  Located  in  the  anterior  urethra.  A  granular  patch  or  stricture. 
The  introduction  of  a  foreign  body,  such  as  a  sound  or  bulbous  bougie, 
or  a  piece  of  calculus,  formed  in  the  bladder  and  making  its  way 
through  the  urethra,  and  finally  the  reflex  irritation  caused  by  a  nar- 
row meatus. 

(c)  Point  of  irritation  not  in  the  urethra,  hut  remote  from  it,  as 
an  operation  about  the  anus,  fissures  or  fistula  of  the  anus,  and  entozoa 
in  the  rectum. 

{d)  Various  psychical  influences,  such  as  shame  or  embarrass- 
ment. 

The  influence   of  these  various  points  of  irritation   is   carried 
through  the  nervous  system  and  causes,  as  a  reflex,  a  contraction  of  I 
the  cut-off  muscle. 


ORGANIC  STRICTURE. 

DEFINITION. 

A  deposit  of  newly-formed  fibrous  connective  tissue  lying  under- 
neath the  mucous  membrane  of  the  urethra  and  interfering  with  its 
dilatability.     This  fibrous  tissue  has  a  tendency  to  contract  and  pro- 
duce a  narrowing  of  the  urethral  calibre. 
(102) 


ORGANIC  STRICTURE.  103 

ETIOLOGY. 

(a)  Inflammation,  which  is  generally  due  to  gonorrhoea,  occa- 
sions an  infiltration  of  small  round  cells  which,  if  not  absorbed,  be- 
comes organized  into  connective  tissue. 

(h)  Traumatism. — A  laceration  or  rupture  of  the  urethra  is 
healed  by  the  process  of  cellular  infiltration,  which  is  thrown  out 
to  a  considerable  extent  and  subsequently  becomes  organized  into 
connective  tissue.  Traumatic  strictures  are  alwaj's  notably  dense  and 
tough. 

PATHOLOGY. 

In  gonorrhoea,  particularly  the  chronic  form,  the  mucous  mem- 
brane of  the  urethra  becomes  the  seat  of  an  infiltration  with  small 
round  cells,  which  extends  into  the  submucous  connective  tissue  and 
finally  involves  the  spongy  tissue  of  the  corpus  cavernosum. 

If  the  infiltration  is  ahsorhed,  stricture  does  not  form;  but  if 
absorption  does  not  take  place  the  infiltrating  small  round  cells  be- 
come transformed  into  spindle  cells,  and  these  are  ultimately  con- 
verted into  dense,  retracting  connective  tissue  (scar-tissue).  The 
transformation  goes  on  slowly,  and  it  requires  at  least  one  or  two 
years  before  the  soft  infiltration  has  become  organized. 

The  following  changes  in  the  tissues  result  from  the  contraction 
of  the  new  fibrous  tissue: — 

The  crypts  and  follicles  of  the  urethra,  which  were  surrounded 
by  the  periglandular  infiltration,  have  been  obliterated  by  the  con- 
traction of  the  fibrous  tissue. 

If  the  corpus  spongiosum  was  involved,  its  meshes  are  obliterated 
in  the  same  way. 

The  calibre  of  the  urethra  is  narrowed  by  the  presence  of  a  mass 
of  firm,  bloodless  scar-tissue,  composed  of  fibrillated  connective-tissue 
cells  lying  underneath  the  mucous  membrane  and  covered  with  many 
layers  of  squamous  epithelial  cells. 

Desquamation  of  these  squamous  epithelial  cells  continues  for 
years,  forming  light  filaments,  which  float  in  the  urine. 


VARIETIES  OF  ORGANIC  STRICTURE. 
I. — Soft  or  recent  stricture  is  merely  an  infiltration  of  the  tis- 
sues with  inflammatory  products,  composed  chiefly  of  small  round 
cells. 


104 


STRICTURE  OF  THE  URETHRA. 


II. — Cicatricial  or  inodular  stricture  is  a  mass  of  new  fibrous 
tissue  which  has  been  formed  by  the  transformation  of  the  soft  in- 
filtration into  true  contractile  connective  tissue,  and  which,  as  it  be- 
comes older,  grows  tougher,  denser,  and  more  elastic. 

A  stricture  is  described  as  linear  when  it  consists  of  a  fine  band 
of  fibres,  annular  when  it  is  composed  of  a  broader  band  encircling 


Fig.  27. — Linear  Stricture. 

the  urethra,  and  tortuous  when  it  is  made  up  of  a  heavy,  irregular 
mass  of  tissue,  producing  a  great  deal  of  distortion  and  narrowing  of 
the  urethral  canal. 

NUMBER. 

Traumatic  stricture  is  always  single,  and  occurs  at  the  point  of 
rupture  in  the  canal. 

Gonorrhoeal  strictures  are  apt  to  be  multiple,  and  it  is  usual  to 
have  two  or  even  three  present  at  the  same  time. 


LOCATION. 

Sir  Henry  Thompson  examined  320  anatomical  preparations  of 
stricture  and  found  that  in  215  cases  the  bulbo-membranous  region 
was  strictured  and  in  105  cases  the  stricture  was  in  the  first  five  inches 
of  the  canal. 

The  prostatic  urethra  is  never  strictured  except  as  a  result  of 
traumatism,  as  inflammation  here  only  produces  a  simple  condensation 


ORGANIC  STRICTURE. 


105 


and  hardening  of  the  submucous  tissues,  but  does  not  narrow  the 
calibre  of  the  canal. 

CHANGES  WHICH  TAKE   PLACE   BEHIND   THE   STRICTURE. 

As  a  result  of  the  obstruction  to  the  free  outflow  of  the  urine, 
the  urethra  becomes  enlarged  and  pouch-like,  and  a  loss  of  its  elas- 
ticity follows,  from  the  frequent  stretching  which  accompanies  each 
act  of  urination. 

This  pouch  retains  a  drop  or  two  of  urine,  which  decomposes, 


Fior.  28. — Annular  Stricture. 


irritates  the  mucous  membrane,  and  causes  a  chronic  inflammation, 
with  a  gleety  discharge. 

The  softened  mucous  membrane  sometimes  ulcerates.  When 
a  sniall  ulceration  occurs,  a  few  drops  of  urine  escape  into  the  tissues 
and  occasion  a  small  abscess,  which  opens  externally,  forming  a  ure- 
thral fistula,  or  the  urine  may  gain  access  to  the  tissues  through  the 
crypts  and  follicles  which  become  dilated. 

If  a  large  ulceration  takes  place,  a  considerable  quantity  of  urine 


106 


STRICTURE  OF  THE  URETHRA. 


Fig.  29. — Changes  behind  a  Stricture.  Dilatation  of  pouch  im- 
mediately behind  Stricture.  Hypertrophy  and  Contraction  of  Bladder. 
Dilatation  of  Ureter  and  Kidney  (Hydronephrosis). 


escapes  into  the  loose  cellular  tissue,  and   extravasation   of  urine 
results. 

CHANGES  IN  BLADDER  AND  KIDNEYS. 

The  increased  effort  on  the  part  of  the  bladder  to  overcome  the 
resistance  offered  by  the  stricture  causes  a  hypertrophy  of  the  blad- 
der-wall. The  muscular  bundles  project  into  the  cavity  of  the  bladder 
and  diminish  its  capacity,  and  contraction  of  the  cavity  occurs. 


ORGANIC  STRICTURE.  207 

In  exceptional  cases  the  walls  become  thinned  and  atrophied,  and 
vesical  atony  resnits. 

RESIDUAL  URINE. 

Definition. — The  urine  which  remains  in  the  bladder  after  the 
patient  has  endeavored  to  evacuate  it  completely. 

Eesidual  urine  exists  in  93  per  cent,  of  cases  of  stricture,  and 
increases  as  the  age  of  the  patient  advances.  It  results  in  cystitis, 
with  vesical  atony  and  damming  back  of  the  urine  upon  the  kidneys. 

The  ureters  and  kidneys  become  distended  and  dilated  from  the 
backward  pressure  of  the  urine,  as  a  result  of  the  muscular  contrac- 
tions of  the  bladder  during  urination. 

The  medullary  tissue  of  the  kidneys  is  atrophied,  and  sac-like 
dilatations  form  (hydronephrosis).  Pyelitis  and  abscess  of  the  kidney 
occur  as  a  result  of  infection  with  bacteria  conveyed  upward  from 
the  decomposing  residual  urine. 


SYMPTOMS. 

(a)  Frequent  urination,  in  the  early  stages  depending  upon  a 
congestion  of  the  posterior  urethra  and  exaggerated  irritability.  Later 
in  the  course  of  the  case  cystitis  causes  the  desire  to  urinate  frequently, 
and  after  the  bladder  has  become  atonied  and  full  of  residual  urine 
the  dribbling  and  incontinence,  or  overdistension,  take  place. 

(b)  Dribbling  after  urination  results  from  some  drops  of  urine, 
w^hich  are  caught  in  the  pouch  behind  the  stricture,  escaping  a  few 
minutes  later. 

(c)  Distorted  or  Smaller  Stream. — The  patient  requires  a  longer 
time  to  pass  his  water,  and  the  stream  is  twisted  or  split. 

(d)  Gleety  discharge  from  the  meatus,  composed  of  muco-pus 
and  shreds  in  the  urine,  is  occasioned  by  the  catarrhal  inflammation 
of  the  mucous  membrane  behind  the  stricture,  from  the  irritation  of 
the  decomposing  urine. 

(e)  Retention  of  urine  occurs  at  times  suddenly  and  early  from 
acute  congestion  of  the  mucous  membrane  at  the  strictured  point, 
and  is  apt  to  be  excited  by  exposure  to  cold  or  wet  and  alcoholic  or 
sexual  excesses. 

Later  in  the  progress  of  the  case  the  retention  is  caused  by  the 
direct  obstruction  of  the  outflow  of  urine,  arising  from  the  slowly 
contractinsr  stricture. 


108  STRICTURE  OF  THE  URETHRA. 

(f)  Pain  in  the  urethra  is  neuralgic  in  character  and  inconstant, 
and  may  never  be  felt. 

(g)  Interference  with  Coitus.  —  The  erections  are  generally 
feeble,  and  premature  ejaculation  occurs  from  congestion  and  irri- 
tability of  the  posterior  urethra,  or  the  semen  may  be  retained  be- 
hind the  stricture  until  the  engorgement  of  erection  subsides,  when 
it  oozes  from  the  meatus. 

DIAGNOSIS. 

The  examination  of  the  urethra,  as  a  rule,  is  not  very  painful, 
but  in  nervous  individuals  it  may  be  injected  with  a  4-per-cent.  solu- 
tion of  cocaine. 

For  purposes  of  diagnosis  the  steel  sound  is  too  inexact,  since, 
without  disclosing  any  details,  it  will  merely  demonstrate  that  an 
obstruction  exists  in  the  urethra  which  prevents  the  sound  from  en- 
tering the  bladder. 


Fig.  30.— Flexible  Bougie  a  Boule. 

By  means  of  the  flexible  bulbous  bougie  it  is  possible  to  feel  the 
slightest  pathological  changes  in  the  canal.  As  the  bulb  is  introduced 
it  glides  along  the  urethra  for  six  inches,  until  it  fetches  up  against 
the  cut-off  muscle,  and  as  it  passes  through  the  membranous  urethra 
it  is  grasped  by  the  muscle,  but  it  feels  freely  movable  again  as  soon 
as  the  posterior  urethra  is  gained.  When  it  reaches  the  sphincter  of 
the  bladder  it  is  slightly  grasped  again,  but  slips  by  and  moves  freely 
in  the  cavity  of  the  bladder. 

The  same  sensations  of  resistance  and  grasping  are  felt  on  with- 
drawing the  bulb,  and  we  should  guard  against  the  error  of  mistaking 
the  resistance  of  the  cut-off  muscle  for  a  stricture  in  the  deep  urethra. 

As  the  bulb  is  moved  the  healthy  mucous  membrane  of  the  ure- 
thra feels  soft  and  velvety,  but,  when  a  stricture  is  impinged  upon,  a 
sensation  of  jolting  is  felt.  There  is  a  perceptible  roughness  of  the 
walls  of  the  urethra,  or  one  or  more  fine  bands,  like  fiddle-strings,  may 


ORGANIC  STRICTURE.  109 

be  discovered.     These  changes  are  more  easily  felt  upon  the  with- 
drawal of  the  bulb. 

The  metal  bulb  is  less  useful  than  the  flexible  bougie,  as  its 
smooth,  polished  surface  glides  over  the  roughnesses  of  the  surface 
without  being  held  by  them. 


Fig.  31. — Metal  Bougies  a  Boule. 

The  Otis  urethrometer  is  chiefly  useful  in  measuring  the  calibre 
and  determining  the  dilatability  of  the  urethra.  It  has  the  advantage 
that  it  can  be  introduced  through  a  narrow  meatus  and  expanded 
behind  the  stricture,  and  we  are  enabled  to  measure  its  calibre  with 
accuracy. 

In  the  case  of  very  tight  strictures,  in  which  the  calibre  is  too 
small  to  allow  the  passage  of  the  smallest  bulbous  bougie,  we  have 
recourse  to  whalebone  filiform  guides. 


\. 


Fig.  32.— Filiform  Whalebone  Guides. 

As  long  as  urine  flows  out  past  a  stricture  we  cannot  speak  of  it 
as  impassable,  although  the  difficulty  of  entering  it  may  be  great 
on  account  of  its  fine,  narrow  lumen  or  because  the  opening  is  not 
central,  but  lying  off  to  one  side. 

In  order  to  find  the  opening  it  may  be  necessary  to  pass  six  or 
eight  guides  down  upon  the  face  of  the  stricture,  and,  with  an  as- 
sistant holding  them  firmly  in  place,  try,  by  twisting  and  manipulat- 
ing successively  one  after  another,  to  find  the  opening  through  the 
stricture. 

It  is  always  desirable  to  inject  3ij  of  olive-oil  into  the  urethra. 


;^10  STRICTURE  OF  THE  URETHRA. 

to  lubricate  the  canal  and  distend  the  narrow  opening  through  the 
stricture. 

Another  manipulation,  which  sometimes  succeeds,  is  to  pass  a 
sound  down  upon  the  face  of  the  stricture,  and  hold  it  pressed  firmly 
for  ten  to  twenty  minutes.  In  this  way  a  certain  amount  of  dilatation 
is  often  accomplished,  and  a  funnel-shaped  depression  in  the  stricture 
is  formed,  with  the  opening  at  the  bottom,  instead  of  being  located 
off  to  one  side,  as  before. 

In  not  a  few  instances  the  opening  through  the  stricture  can  be 
discovered  by  visual  inspection  through  an  endoscope. 

If  great  difficulty  has  been  experienced  in  introducing  a  guide 
through  a  stricture,  it  is  better  not  to  withdraw  it  and  take  the 
chances  of  getting  it  in  again,  but  tie  it  in,  and  leave  it,  either  for 
the  purpose  of  continuous  dilatation  or  for  operation. 

TREATMENT. 

All  strictures,  no  matter  where  they  are  located,  if  soft  and  recent, 
are  best  treated  by  gradual  dilatation.  After  the  small  round-celled 
infiltration  has  become  converted  into  fibrillated  connective  tissue  and 
is  dense  and  contracted,  dilatation  no  longer  meets  with  the  success 
which  would  have  attended  its  use  in  the  earlier  stages.  Even  in  these 
old  cases,  howc  er,  we  can  in  many  instances  enlarge  the  calibre  of 
the  stricture  and  maintain  it  subsequently,  by  means  of  an  occasional 
passage  of  a  sound,  at  a  size  which  does  not  obstruct  the  urinary  out- 
flow. On  this  ai^count  it  is  always  well,  in  nearly  every  case,  to  try 
the'  effects  of  d^^atation  before  proceeding  to  the  more  heroic  meas- 
ures of  operation. 

In  private  practice,  where  patients  are  more  regardful  of  their 
health,  and  seek  medical  advice  early,  the  larger  proportion  of  strict- 
ures are  amenable  to  treatment  by  dilatation.  In  hospital  practice,  on 
the  other  hand,  patients  are  careless  and  neglect  themselves,  and  when 
they  do  apply  for  treatment  the  stricture  is  apt  to  be  so  extensive  and 
so  firm  and  dense  that  operation  is  the  only  resource. 

For  purposes  of  dilatation  we  have  recourse  to: — 

(a)  Flexible  bougies. 

(b)  Steel  sounds,  with  the  curve  recommended  by  Van  Buren. 

(c)  Oberlaender  dilator. 

Unlike  the  operative  treatment,  we  may  consider  both  regions  of 
the  urethra  together  in  discussing  the  treatment  by  dilatation. 

In  the  case  of  a  stricture,  particularly  if  located  in  the  bulb  or 


Fig.  33.— Stricture  of  the  Bulbo-membraiions  Urethra  and  False 
Passage.  The  instrument  has  been  forced  through  the  tissues  into 
the  Bladder. 


(Ill) 


ORGANIC  STRICTURE. 


113 


membranous  urethra,  which  is  below  No.  16  French  in  calibre,  we 
should  always  begin  dilating  with  an  elastic  bougie. 

If  a  metal  sound  is  used,  there  is  always  danger  of  lacerating  the 
inflamed  and  degenerated  mucous  membrane  and  pushing  the  sound 
into  the  periurethral  tissue,  making  a  false  passage.  If  this  accident 
occurs,  the  point  of  the  sound  is  felt  to  be  not  in  the  median  line, 
and  is  grasped  firmly  by  the  tissues,  and  a  finger  in  the  rectum  readily 
detects  the  deflection  of  the  instrument.  Free  haemorrhage  from  the 
meatus  follows  the  withdrawal  of  the  sound. 

The  treatment  of  such  an  accident  consists  in  rest,  urethral  and 
urinary  antisepsis,  and  the  avoidance  of  instrumentation  for  three 
weeks  until  the  laceration  has  healed. 

In  using  an  elastic  bougie  we  should  select  a  size  which  is  small 
enough  not  to  lacerate  the  tissues.  When  the  bougie  enters  the 
stricture  the  sensation  of  its  being  engaged  and  grasped  is  perceived. 
If  it  is  held  very  tightly,  rather  than  attempt  to  push  it  ahead,  it  is 
better  to  wait  a  few  moments  till  the  spasm  has  relaxed,  and  then  push 
the  instrument  farther  along. 

After  the  elastic  bougie  has  been  passed  through  the  stricture,  it 
can  be  withdrawn  at  once.  There  is  no  object  in  allowing  it  to  remain, 
since  it  is  compressible  and  cannot  produce  any  absorption  in  the 
stricture;  it  simply  dilates  it  mechanically.  If  the  instrument  has 
been  introduced  with  comparative  ease,  and  without  much  pain,  we 
may  then  introduce  another  of  a  larger  size. 

At  the  next  sitting,  which  should  not  take  place  before  two  to 
three  days  have  elapsed,  we  should  first  introduce  the  number  passed 
upon  the  former  occasion  and  then  use  larger  sizes. 

When  the  flexible  bougie  No.  16  French  can  be  introduced  with 
ease,  we  should  begin  gradual  dilatation  with  the  steel  sound.  It  is 
important  for  the  beginner  to  cultivate  a  suitable  techiique  in  using 
sounds,  as  unnecessary  pain  and  sometimes  actual  damage  to  the  tis- 
sues are  caused  by  clumsy  manipulation.  The  sound  is  sterilized  by 
boiling  or  passing  through  the  flame  of  a  spirit-lamp,  lubricated  with 
vaselin  or  oil,  and  should  be  warm. 

As  the  patient  lies  upon  a  table  the  operator  stands  upon  his  left 
side.  Sir  Henry  Thompson  advises  that  for  the  moment  the  operator 
should  forget  all  his  anatomical  Tcnoicledge,  and  let  the  sound  slip 
through  the  urethra  hy  its  oivn  weight,  guiding  it  with  the  utmost 
gentleness,  and  in  no  case  should  any  pushing  or  prodding  or  force  be 
used.     This  is  well  accomplished  by  holding  the  sound  stationary,  in 


114 


STRICTURE  OF  THE  URETHRA. 


a  line  with  Poupart's  ligament,  and  drawing  the  penis  up  over  it  until 
the  point  of  the  sound  has  reached  the  membranous  urethra.  The 
sound  is  then  brought  into  the  median  line  of  the  body,  and  as  the 
point  passes  through  the  membranous  urethra  the  handle  will  of  itself 
describe  the  arc  of  a  circle  and  gradually  sink  down  between  the  thighs 
and  parallel  with  them.  When  the  handle  is  completely  depressed, 
it  may  be  rotated  freely  from  side  to  side,  thus  demonstrating  that 
the  point  lies  in  the  bladder  and  is  freely  movable. 

The  largest-sized  sound  should  be  selected  which  will  pass 
through  the  stricture  without  using  force,  withdrawn,  and  a  still  larger 
size  introduced.  It  is  desirable,  in  order  to  obtain  the  effect  of  the 
prolonged  pressure,  not  to  withdraw  the  sound  at  once,  but  to  leave  it 
lying  in  the  stricture  for  from  five  to  fifteen  minutes. 

At  the  next  sitting  we  should  begin  with  the  sound  last  intro- 
duced, withdraw  it,  and  pass  the  next  larger  size.  The  sounds  should 
not  be  passed  too  frequently,  and  the  rule  is  always  to  wait  until  the 
reaction  has  subsided  before  passing  the  sound  again.  The  intervals 
vary,  depending  on  the  amount  of  reaction,  from  four  to  seven  days. 

There  are  different  views  as  to  the  extent  to  which  it  is  neces- 
sary to  carry  the  dilatation,  some  authorities  claiming  that  No.  25 
French  is  sufficient,  others  maintaining  that  No.  30  French  is  the 
proper  calibre.  In  any  case  there  is  always  danger  of  recontradion 
unless  the  sound  is  passed  at  occasional  intervals,  in  order  to  maintain 
the  maximum  calibre,  for  at  least  eighteen  months.  We  can  intro- 
duce the  sound  every  week,  and  then  increase  the  intervals  to  once 
in  two,  four,  six,  eight,  and  twelve  weeks. 

Effects  upon  the  stricture  of  passing  sounds  are  twofold,  accord- 
ing to  Oberlaender  and  Wossidlo: — 

I.  The  mechanical  stretching  to  which  it  is  subjected. 

II.  A  change  in  the  vital  functions  of  the  tissues. 

As  a  result  of  the  distension,  small  tears  occur  in  the  mucous 
membrane  or  the  stricture-tissue,  as  evidenced  by  slight  bleeding.  In 
a  few  hours  a  profuse  mucous  secretion  occurs,  indicating  that  a  melt- 
ing of  the  stricture-callus  is  taking  place  in  consequence  of  the  re- 
action. Under  the  increased  vascularization  which  sets  in,  the  strict- 
ure is  partially  absorbed. 

After  dilatation  to  No.  25  or  30  has  been  accomplished,  the  sound 
only  acts  upon  the  narroirest  part  of  the  stricture,  and  when  it  lies 
loosely  here  it  accomplishes  nothing  further  in  the  way  of  producing 
absorption  of  the  stricture-callus,  but  only  keeps  its  calibre  mechanic- 


ORGANIC  STRICTURE.  115 

ally  dilated.  But  in  many  cases  the  stricture-tissue  begins  to  recon- 
tract  as  soon  as  the  use  of  sounds  is  discontinued. 

Oberlaender  claims  that  by  dilating  the  stricture  to  more  than  No. 
30  French,  even  40  or  45,  the  fibrous  tissue  of  the  stricture  is  trans- 
formed into  a  "dead  scar,"  which  has  no  longer  any  tendency  to  con- 
tract. He  states  that,  by  systematic  examinations  with  the  endoscope, 
an  evident  improvement,  which  is  perceptible  to  the  eye,  occurs  only 
after  the  dilatation  of  the  urethra  has  exceeded  No.  30  French. 

When  the  meatus  is  of  normal  size,  it  will  not  admit  a  sound 
large  enough  to  accomplish  this  result,  and,  even  if  meatotomy  is  done, 
the  meatus  can  only  be  cut  to  a  size  sufficient  to  admit  a  No.  30 
French  sound,  and  this  calibre  is  not  enough  to  accomplish  the  over- 
distension of  the  urethra,  according  to  the  views  of  Oberlaender.  On 
this  account  he  has  devised  the  Oberlaender  dilator,  which  can  be  in- 
troduced, with  the  blades  closed,  through  a  small  meatus;  after  it  is 
in  place  the  blades  are  separated  by  turning  the  screw  at  the  end,  and 
we  can  get  any  amount  of  distension  of  the  urethra  which  we  may 
desire,  even  as  high  as  No.  45  French.  It  should  be  distinctly  under- 
stood that  forcible  dilatation  or  divulsion  is  not  intended,  but  only  a 
gradual  and  temporary  dilatation  of  the  stricture.^ 

Technique. — The  urethra  is  cocainized,  and  the  dilator,  which  is 
provided  with  a  rubber  cover,  is  oiled  and  introduced.  If  the  sound 
which  was  passed  on  the  case  previously  was  No.  26,  we  separate  the 
blades  of  the  dilator  to  one  number  higher:  i.e.,  to  No.  27. 

The  blades  should  be  separated  very  slowly,  and  after  we  have 
screwed  them  apart  one  number,  as  indicated  on  the  dial,  we  should 
wait  until  the  pain  has  subsided,  and  then  increase  the  separation  to 
the  next  higher  number. 

After  each  dilatation  a  muco-purulent  secretion  occurs,  which 
indicates  the  melting  and  absorption  of  the  stricture-callus.  If  the 
discharge  is  profuse  in  quantity,  it  indicates  that  the  stretching  has 
been  too  vigorous.  The  usual  intervals  for  dilatation  are  about  ten 
days,  on  the  average;  and  at  each  sitting  the  dilatation  should  be 
increased  from  one  to  two  numbers. 

The  extent  to  which  the  stricture  should  be  finally  dilated  is  a 
matter  of  individual  experience,  and  beginners  generally  make  the 
mistake  of  dilating  too  rapidly.     A  sharp  bleeding  or  an  excessive 


^  KoUmann's  dilator  is  a  more  recent  instrument,  and  is  to  be  preferred, 
as  it  is  provided  with  four  dilating  blades,  and  is  less  apt  to  cause  a  laceration 
of  the  urethra  than  Oberlaender's  dilator. 


l^Q  STRICTURE  OF  THE  URETHRA. 

secretion  following  dilatation  is  an  indication  that  an  error  has  been 
made  in  the  technique,  and  that  the  dilatation  has  been  too  rapid  or 
too  great.  If  such  an  accident  occurs,  it  is  necessary  to  wait  from 
three  to  six  weeks,  until  all  tenderness  of  the  urethra  has  disappeared 
and  the  secretion  has  diminished  and  is  but  slight  in  amount. 

In  regard  to  the  extent  to  which  dilatation  should  be  carried  be- 
fore the  stricture  can  be  said  to  be  cured,  Oberlaender  states  that  the 
endoscope  is  the  only  guide.  The  mucous  membrane  should  show  a 
normal  healthy  surface  and  the  fibrous  tissue  should  be  transformed 
into  a  "dead  scar,"  which  has  no  longer  any  tendency  to  contract.  As 
soon  as  this  condition  is  attained,  all  further  dilatation  can  be  sus- 
pended, quite  irrespective  as  to  whether  the  stricture  has  been  dilated 
to  No.  28  or  30  or  to  40  or  45  French. 

As  with  the  use  of  sounds  after  active  treatment  has  ceased,  the 
stricture  should  still  be  dilated,  with  the  dilator,  at  occasional  inter- 
vals to  prevent  relapses. 

Relapses  sometimes  occur,  and  can  be  recognized  by  the  endoscope 
and  treated  with  dilatations  again,  before  any  decided  contraction  has 
had  time  to  occur.  For  this  reason,  it  is  desirable  to  examine  cases 
with  the  endoscope  at  intervals  of  three  or  six  months  after  treatment 
has  ceased. 

Strictures  of  very  small  calibre,  which  are  so  tight  as  not  to  per- 
mit the  passage  of  the  smallest  flexible  bougie,  can  often  be  penetrated 
by  means  of  the  filiform  whalebone  guide.  After  this  instrument  has 
penetrated  the  stricture  and  the  end  has  entered  the  bladder  there 
are  three  courses  open  to  us: — 

(a)  Continuous  Dilatation.  —  If  a  bougie  is  passed  through  a 
stricture  which  grasps  it  tightly  and  is  left  in  place  for  twenty-four 
hours,  the  stricture  ulcerates  superficially,  but  widens  rapidly,  so  that 
the  bougie  lies  loosely  within  it,  and  can  be  withdrawn,  and  a  larger 
instrument  introduced  to  take  its  place. 

In  cases  of  retention  of  urine,  a  guide  may  be  left  tied  in  the 
bladder,  and  the  urine  escapes,  flowing  away  alongside  of  the  guide. 

On  the  following  days  larger  instruments  may  be  introduced  and 
tied  in  until  the  stricture  is  sufficiently  dilated  to  admit  being  treated 
with  sounds. 

Continuous  dilatation,  while  formerly  much  in  vogue,  is  now 
almost  obsolete,  methods  b  and  c  having  taken  its  place. 

(b)  Tunneled  Sound  and  Gradual  Dilatation. — A  tunneled  sound 
is  threaded  over  the  guide  and  introduced  through  the  stricture,  dilat- 


TREATMENT  BY  SURGICAL  OPERATION.  117 

ing  it.  The  sound  is  then  withdrawn  and  a  larger  one  introduced  in 
the  same  way.  This  is  a  very  useful  method  of  treating  tight  strict- 
ures, which  are  not  too  hard  and  fibrous  to  admit  of  gradual  dilatation. 


Fiff.  34.— Tunneled  Sound. 


In  case  of  retention  of  urine,  where  it  is  necessary  to  relieve  a  dis- 
tended bladder,  Gouley's  tunneled  catheter  can  be  used  in  place  of  the 
tunneled  sound,  and  the  urine  withdrawn  through  it,  by  pulling  out 
the  stylet  and  thus  making  the  hollow  shaft  permeable. 


A-^ 


Fig.  3.5. — Gouley's  Tunneled  Catheter. 

(c)  Immediate  Operation.  —  Internal  urethrotomy  by  Maison- 
neuve's  urethrotome  or  external  urethrotomy.  (See  the  following  sec- 
tion on  the  operative  treatment  of  stricture.) 


TREATMENT  OF  STRICTURE  BY  SURGICAL  OPERATION. 

As  we  have  before  stated,  a  soft  or  recent  stricture,  no  matter  in 
what  part  of  the  canal  it  is  located,  is  best  treated  by  gradual  dilata- 
tion with  sounds  or  dilators;  but,  as  the  stricture  becomes  older,  it 
grows  dense,  firm,  and  fibrous,  and  the  gradual  dilatation  is  no  longer 
practicable. 

We  are  obliged  to  resort  to  a  division  or  cutting  through  the 
stricture-band  by  means  of  the  knife,  and  to  that  end  we  employ  two 
different  operations: — 

(a)  Internal  urethrotomy. 

(b)  External  urethrotomy. 


j^g  STRICTURE  OF  THE  URETHRA. 

The  choice  of  the  operation  depends  entirely  upon  the  point  in 
the  urethra  at  which  the  stricture  is  located,  and  for  the  purpose  of 
making  the  indications  for  operation  clear  we  can  divide  the  urethra 
into  two  regions: — 

Eegion  I  extends  from  the  meatus  backward  for  a  distance  of 
five  inches,  and  its  termination  corresponds  to  the  peno-scrotal  junc- 
tion. 

Eegion  II  includes  the  bulbous  and  membranous  urethra.  It 
extends  from  a  point  five  inches  distant  from  the  meatus  back  as  far 
as  the  prostatic  urethra. 

The  operation  of  internal  urethrotomy  through  the  meatus  is 
restricted  to  Eegion  I,  and  external  urethrotomy  through  a  perineal 
incision  is  only  applicable  to  strictures  located  in  Eegion  II. 


INTERNAL  URETHROTOMY. 

Preparatory  Treatment. — Before  any  operation  on  the  urethra  the 
urine  should  be  rendered  aseptic  by  salol,  gr.  x  t.  i.  d.,  and  if  strongly 
acid  it  should  be  neutralized  by  citrate  of  potash  or  bicarbonate  of 
potash. 

The  urethral  canal  should  be  irrigated  with  Thiersch's  fluid  or 
salt  solution  to  free  it  from  germs  as  much  as  possible. 

It  is  desirable  to  fill  the  bladder  with  Thiersch's  fluid  by  means 
of  a  catheter,  and  leave  the  fluid  in,  to  flow  out  after  the  operation, 
bathing  the  cut  surfaces  and  diluting  the  urine,  when  the  patient 
urinates  later. 

Anaesthetic. — A  4-per-cent.  solution  of  cocaine  is,  as  a  rule,  sufii- 
cient,  unless  in  the  case  of  very  extreme  strictures,  which  require  a 
general  anaesthetic. 

The  technique  of  internal  urethrotomy  is  as  follows:  If  the 
meatus  is  small,  it  should  be  incised  on  the  floor  to  No.  30  French, 
and  any  stricture-bands  which  are  within  an  inch  of  it  should  be 
divided  at  the  same  time  with  a  straight,  probe-pointed  bistoury. 

The  Otis  urethrotome,  preferably  with  Band's  modification,  is 
introduced  into  the  urethra  closed.  After  its  point  has  entered  hehind 
the  stricture  the  blades  are  separated,  by  means  of  the  screw,  to  the 
full  extent  the  calibre  of  the  stricture  will  allow.  The  instrument  is 
then  withdrawn  until  the  projection  at  the  end  catches  against  the 


INTERNAL  URETHROTOMY.  119 

stricture  and  is  held.  We  know  by  the  feeling  of  resistance  that  the 
projection  which  conceals  the  knife  lies  in  close  contact  with  the  point 
we  wish  to  cut.  The  knife  is  then  withdrawn  for  an  inch,  cutting 
through  the  stricture,  and  toward  the  roof  of  the  urethra.     And  we 


Fig.  36. — Otis  Urethrotome,  as  Modified  by  Rand. 

can  afterward  readily  demonstrate  that  the  stricture  has  been  cut 
through  by  separating  the  blades  more  widely  than  was  before  pos- 
sible. 

The  knife  is  again  pushed  back  into  its  place  of  concealment  in 
the  instrument,  and  the  urethrotome  is  drawn  out  toward  the  meatus, 
and  any  other  stricture-bands  present  are  cut  in  the  same  way. 

In  every  case  treated  by  internal  urethrotomy  the  question  arises: 
"How  deep  shall  we  make  the  incision  through  the  stricture?"  This 
is  still  a  point  under  discussion,  since  almost  every  author  has  his 
own  line  of  procedure.  Dr.  Otis  devised  a  scale  of  measurements  of 
the  penis,  as  a  guide  to  depth  of  the  incision,  and  claims  that  a  penis 
three  inches  in  circumference  should  be  cut  to  admit  a  No.  30  French 
sound,  while  a  penis  four  inches  in  circumference  should  be  cut  so 
that  a  No.  38  sound  can  be  passed. 

I  believe  we  will  have  better  results  by  treating  each  case  on  its 
individual  merits.  The  stricture  which  is  comparatively  light  and  does 
not  involve  the  whole  corpus  spongiosum  may  be  completely  divided, 
as  shown  by  the  entire  absence  of  resistance  when  the  blades  of  the 
urethrotome  are  separated,  after  cutting  the  stricture. 

In  the  ease  of  a  heavy  stricture  which  involves  all  the  corpus 
spongiosum  we  cannot  divide  the  whole  thickness  of  the  stricture,  but 
must  content  ourselves  with  cutting  it  through  partially,  and  trust  to 
keeping  the  channel  open  by  passing  sounds  frequently  for  the  rest  of 
the  patient's  life. 

After  the  stricture  has  been  cut  to  the  extent  which  we  desire 
and  the  urethrotome  has  been  withdrawn,  a  bulbous  bougie,  No.  30 
or  32  French,  is  introduced  into  the  canal,  to  make  sure  that  all 
bands  are  completely  divided. 


j^20  STRICTURE  OF  THE  URETHRA. 

After-treatment. — The  patient  should  be  kept  in  bed  and  on  light 
diet  and  directed  to  drink  freely  of  water  and  milk  to  dilute  the  urine. 

In  order  to  keep  the  cut  surfaces  from  growing  together,  a 
straight  sound  can  be  passed,  every  day  for  the  first  week  and  sub- 
sequently every  second  da}^  and,  after  a  month,  once  a  week.  Later 
the  passage  of  the  sound  need  only  take  place  once  a  month;  but 
there  is  always  danger  of  recontradion  unless  a  sound  is  passed  at 
intervals. 

Dangers  of  Internal  Urethrotomy. — Mortality,  2  to  5  per  cent. 

(a)  Haemorrhage. 

(h)  Infiltration  of  urine  through  wound  into  tissues,  producing 
abscesses  and  septicaemia. 

(c)  Urinary  fever.  It  is  especially  important  to  see  that  the  kid- 
neys are  healthy  before  doing  an  internal  urethrotomy. 

(d)  Deformities  of  the  penis  subsequently. 

When  a  deep  cut  is  made  into  the  roof  of  the  urethra  a  large 
amount  of  scar-tissue  is  formed  in  healing.  This  scar  subsequently 
contracts,  and  bends  the  penis  into  the  shape  of  a  bow,  which  causes 
erections  to  be  painful,  and  renders  coitus  difficult  or  impossible. 


Fig.  37. — ]\Iaisoiineuve's  Urethrotome. 

Strictures  of  small  calibre,  under  No.  18  French,  are  not  large 
enough  to  admit  the  passage  of  an  Otis  urethrotome.  In  these  cases 
a  filiform  guide  should  be  passed  through  the  stricture  and  by  means 
of  (a)  Maisonneuve's  urethrotome  the  stricture  can  be  divided,  from 
before  backward,  and  afterward  cut  larger  with  an  Otis  urethrotome, 
or  we  can  introduce  over  the  guide  (&)  a  divulsor  and  stretch  the 
stricture  so  that  an  Otis  urethrotome  can  be  used. 

The  operation  of  divulsion  as  formerly  practiced  has  been  entirely 
superseded,  as  it  is  inexact  and  dangerous,  producing  extensive  lacera- 
tions of  the  urethra,  which  are  followed  by  hsemorrhage  and  septic 
absorption. 

Summary  of  Indications  for  Internal  Urethrotomy. — This  opera- 
tion is  applicable  only  to  stricture  of  the  pendulous  urethra  which 


EXTERNAL  URETHROTOMY.  131 

is  dense  and  fibrous  and  cannot  be  treated  by  gradual  dilatation  with 
sounds,  and  located  less  than  five  inches  from  the  meatus. 
It  is  especially  adapted  to  the  following  varieties: — 

(a)  Distinctly  fibrous  or  non-dilatable  stricture. 

(b)  Eesilient  stricture.  (Definition:  Elastic  and  India-rubber- 
like,  contracting  quickly  after  instrumentation.) 

(c)  Irritable  stricture.  (Definition:  Standing  instrumentation 
badly  and  easily  excited  to  inflammation.) 

(d)  Cases  where  urethral  fever  follows  each  introduction  of  a 
sound. 

When  a  stricture  is  located  more  than  five  inches  from  the  meatus, 
internal  urethrotomy  is  no  longer  a  suitable  operation,  on  account  of 
the  danger  of  haemorrhage,  which  is  difficult  to  control.  The  blood 
flows  backward,  overcomes  the  resistance  of  the  cut-off  muscle,  and 
fills  the  bladder. 

The  means  of  controlling  the  bleeding  are  as  follow: — 

(a)  Pressure  on  the  perineum  by  means  of  a  crutch,  firmly  ap- 
plied against  it. 

(b)  Introduction  of  a  full-sized  catheter  into  the  bladder,  which 
makes  pressure  on  the  urethral  walls  and  closes  the  bleeding  vessels. 

(c)  Perineal  section  and  introduction  of  a  catheter  through  the 
wound  into  the  bladder,  with  firm  gauze  packing  around  it. 

Another  danger  is  infiltration  of  urine,  which  soaks  into  the  tis- 
sues through  the  cut  and  produces  ahscess  and  sei}sis. 


EXTERNAL  URETHROTOMY. 

In  consequence  of  the  dangers  of  haemorrhage  and  infiltration  of 
urine,  we  have  recourse  to  the  operation  of  external  urethrotomy 
through  the  perineum  when  the  stricture  is  located  in  the  bulbous  or 
membranous  urethra,  viz.:    in  Eegion  II. 

Forms  of  Operation. — (a)  With  a  filiform  guide:  Gouley's  opera- 
tion, modified  by  Rand. 

(&)  Without  a  guide:   Wheelhouse  operation. 

Gouley's  Operation  With  a  Guide. — Technique. — A  filiform  guide 
is  introduced  through  the  stricture  and  into  the  bladder  and  a  tun- 
neled sound  is  slid  over  the  guide,  till  its  point  rests  against  the 
stricture.  The  urethra  is  opened  in  the  perineum,  by  cutting  down 
upon  the  end  of  the  tunneled  sound. 


122 


STRICTURE  OF  THE  URETHRA. 


The  sound  is  withdrawn,  the  guide  being  held  with  forceps,  to 
prevent  its  being  pulled  out  of  the  bladder. 

The  free  end  of  the  whalebone  guide  is  then  brought  out  through 


Fig.  38. — Rand's  Tunneled  Sound. 


Fig.  39.— Gouley's  Catheter-staff. 


Fig.  40. — Tunneled  Knife. 


the  wound  (the  other  end  remaining  in  situ,  in  the  bladder).  Eand's 
tunneled  knife  is  then  threaded  over  the  guide  and  pushed  through 
the  stricture,  dividing  its  fibres,  into  the  bladder.  A  gorget  is  intro- 
duced into  the  bladder,  and  any  undivided  fibres  of  the  stricture  are 


EXTERNAL  URETHROTOMY. 


123 


cut  with  a  blimt-pointed  straight  bistoury,  using  the  gorget  as  a 
director. 

The  operation  of  external  urethrotomy  is  rendered  comparatively 
simple,  if  we  are  able  to  introduce  a  filiform  guide  into  the  bladder, 
and  it  may  be  impossible  to  reach  the  bladder  without  the  assistance 
furnished  by  the  guide.  For  that  reason  it  is  desirable  to  persevere 
in  our  efforts  to  get  a  guide  in;  when  we  fail,  however,  we  are  obliged 
to  do  the  operation  of 

External  Urethrotomy  Without  a  Guide,  as  Devised  by  Wheel- 
house. — Technique. — A  Wheelhouse  staff  is  introduced  into  the  ure- 


Fig.  42. — External  Urethrotomy.     Wheelhouse  Operation, 
Exposing  the  Urethra. 


Fig.  43.— Wheelhouse  Staff. 


thra,  till  its  end  rests  against  the  face  of  the  stricture.  The  urethra 
is  opened  through  the  perineum,  cutting  down  upon  the  end  of 
the  staff.     The  wound  in  the  urethra  is  retracted  by  small  hooks  on 


■^24  STRICTURE  OF  THE  URETHRA. 

either  side,  and  the  upper  angle  of  the  wound  is  held  up  by  hooking 
the  projecting  end  of  the  staff  against  it  and  drawing  it  as  much  out 
of  the  way  as  possible. 

Search  is  then  made  for  the  distal  end  of  the  urethra  by  means 


Fig.  44. — Small  Tenaculum  for  Holding  Apart  Incised  Urethra 
in  External  Urethrotomy. 


(T 


Fig.  45. — Arnott's  Grooved  Probe. 


Fig.  46. — Gouley's  Beaked  Bistoury. 

of  Arnott's  grooved  probe  or  a  filiform  guide  and  by  inspection.  If 
the  opening  is  found  and  the  probe  introduced,  a  Gouley  knife  is 
slipped  along  the  groove  in  the  probe  and  the  stricture  is  cut  through. 

In  case  of  failure  to  find  the  opening  we  may  have  recourse  to 
Guiteras's  trocar.  The  rami  of  the  pubis  form  a  triangle,  with  the 
symphysis  at  the  ap€x.  The  urethra  lies  immediately  under  and  one- 
half  an  inch  below  the  symphysis. 

If  our  anatomical  knowledge  enables  us  to  locate  the  urethra 
accurately,  by  sfahhing,  in  the  proper  place  with  the  trocar,  we  will 
puncture  the  stricture-tissue,  and  the  trocar  will  lie  in  the  prostatic 
urethra  beyond,  as  can  be  demonstrated  by  pushing  the  trocar  along 
through  it,  until  it  reaches  the  bladder,  and  withdrawing  the  stylet, 
when  a  stream  of  urine  will  flow  through  the  hollow  cannula.  A  knife 
is  then  introduced  along  the  groove  in  the  instrument  and  the  strict- 
ure divided  in  the  usual  way. 

In  the  event  of  this  procedure  not  being  successful  we  may  have 
recourse  to  retrograde  catheterization.  This  operation  consists  in 
making  a  suprapubic  cystotomy  and  introducing  a  staff  into  the  blad- 
der and  through  the  prostatic  urethra  and  along  the  canal  until  its 
further  progress  is^barred  by  the  stricture,  through  which  it  cannot 
pass.  The  end  of  the  staff  is  felt,  covered  by  stricture-tissue,  by  means 
of  a  finger  in  the  wound,  and  the  tissue  which  intervenes  between  the 
end  of  the  staff  and  the  perineal  wound  is  cut  through  with  a  knife, 


EXTEENAL  URETHROTOMY.  125 

in  this  way  bringing  the  end  of  the  staff  into  view  in  the  wound. 
The  urethra  is  thus  made  again  one  continuous  canah 

We  may  have  recourse  to  still  another  procedure,  which  is  to  let 
the  patient  recover  from  his  ansesthetic  and  when  consciousness  is 
restored  and  the  bladder  is  full  of  urine,  if  the  patient  endeavors  to 
pass  water,  a  few  drops  of  urine  may  be  seen  to  escape  at  one  point 
in  the  perineal  wound,  thus  indicating  the  location  of  the  end  of  the 
urethra,  which  had  not  been  discoverable  before. 

Treatment  After  External  Urethrotomy. — Hcemorrhage  during 
the  operation  is  controlled  by  clamping  the  bleeding  vessels  with 
artery-forceps,  which,  if  necessary,  may  be  left  in  situ  for  twenty-four 
hours  in  the  wound,  before  being  removed.  As  a  rule,  this  is  unneces- 
sary, as  the  general  oozing  can  be  perfectly  controlled  by  firm  pressure 
by  means  of  gauze,  packed  into  the  wound  and  around  the  catheter. 

An  important  indication  is  to  secure  good  drainage  of  the  bladder 
and  i^revent  the  urine  from  coming  in  contact  with  the  freshly  made 
wound  until  septic  absorption  is  guarded  against  by  the  formation  of 
granulations.  This  is  readily  accomplished  by  carrying  a  No.  30 
French  catheter  through  the  wound  and  into  the  bladder,  and  taking 
a  stitch  through  both  lips  of  the  wound  and  the  catheter  to  prevent 
it  from  being  forced  out.  The  end  of  the  catheter  is  attached  to  a 
long  tube,  which  drains  into  a  bottle  on  the  floor. 

In  a  case  where,  in  addition  to  cutting  a  stricture  in  the  deep 
urethra,  a  stricture  in  the  anterior  part  of  the  canal  had  been  divided 


Fig.  47.— Straight  Steel  Sound. 

by  internal  urethrotomy,  a  straight  sound  should  be  passed  through 
the  meatus  and  anterior  urethra  down  to  the  catheter  on  the  second 
day  after  the  operation  and  upon  every  alternate  day  until  the  drain- 
age tube  is  removed  from  the  wound  and  bladder.  The  gauze  pack- 
ing should  be  removed  from  around  the  tube  in  forty-eight  hours 
and  the  wound  irrigated  and  repacked.  It  is  desirable  to  irrigate  the 
bladder  with  Thiersch's  fluid  every  day.  About  the  seventh  day  after 
the  operation,  when  granulations  have  formed,  the  catheter  is  re- 
moved from  the  wound  and  a  curved  sound  passed  through  the  meatus 


126 


STRICTURE  OF  THE  URETHRA. 


into  the  bladder.  The  sound  is  passed  every  second  day  into  the  blad- 
der until  the  perineal  wound  is  healed  and  the  patient  discharged. 

The  patient  may  be  allowed  to  get  out  of  bed  and  sit  in  a  chair 
a  week  after  the  operation,  and  the  ability  to  hold  the  water  and  pass 
it  at  will  is  regained  about  the  same  time. 

Recontraction  of  the  stricture  is  almost  certain  to  take  place, 
after  division  of  a  heavy  stricture,  unless  the  patient  passes  a  sound, 
at  occasional  intervals,  for  the  rest  of  his  life,  and  this  fact  should  be 
earnestly  impressed  upon  him,  so  that  he  may  not  neglect  the  pre- 
caution. 

Resume. — External  urethrotomy  is  applicable  only  to  strictures 
located  more  than  five  inches  from  the  meatus:  i.e.,  in  the  bulbous 
and  membranous  urethra. 

Summary  of  indications: — 

(a)  Eupture  of  urethra. 

(6)  Urinary  infiltration. 

(c)  Impassable  stricture  complicated  by  retention  of  urine. 

{d)  Tough  fibrous  stricture  of  small  calibre  which  is  difficult  to 
dilate. 

(e)  Traumatic  stricture. 


MISCELLANEOUS. 

Stricture  at  the  meatus  may  be  congenital  or  the  result  of  gon- 
orrhoea. In  these  cases  dilatation  is  useless,  and  the  proper  procedure 
is  meatotomy,  which  is  accomplished  by  cutting  the  meatus  upon  the 
floor  by  means  of  a  straight  probe-pointed  bistoury. 

There  is  a  tendency  on  the  part  of  the  cut  surfaces  to  unite  after- 
ward, which  is  counteracted  by  dilating  the  meatus  three  times  daily 
with  a  sound,  or  preferably  a  glass  cone. 

Stricture  Complicated  by  a  False  Passage. — A  large  number  of 
cases  of  old  deep-seated  stricture,  which  have  been  under  instrumenta- 
tion a  number  of  times,  are  apt  to  have  one  or  more  false  passages, 
which  have  been  made  by  the  bungling  use  of  a  sound. 

A  false  passage  adds  to  the  difficulty  of  entering  the  bladder  with 
a  catheter  or  sound,  because  it  is  very  apt  to  engage  the  point  of  the 
instrument  and  "pocket"  it. 

In  these  cases  the  filiform  hougie  is  very  serviceable  in  furnishing 


TREATMENT  OF  INTRACTABLE  STRICTURE.  127 

a  guide  into  the  bladder.  Our  plan  of  procedure  is  to  introduce  one 
guide  after  another  through  the  urethra,  in  hopes  that  one  of  them 
will  slip  past  the  opening  of  the  false  passage,  pass  through  the  strict- 
ure, and  thus  into  the  bladder. 

Combined  external  and  internal  urethrotomy  is  always  demanded 
when  both  jDcndulous  and  bulbous  portions  of  the  urethra  are  the 
seat  of  strictures. 

It  is  also  often  a  good  plan  to  open  the  deep  urethra  and  drain 
the  bladder  with  a  catheter  after  an  extensive  internal  urethrotomy, 
in  order  to  prevent  the  urine  from  passing  over  the  fresh  cut  surface 
in  the  urethra  and  causing  urinary  fever. 


TREATMENT  OF  INTRACTABLE  STRICTURE  BY  RESECTION 
OF  A  PORTION  OF  THE  URETHRA. 

Occasionally  dense  fibrous  strictures  of  the  deep  urethra,  with  a 
large  amount  of  periurethral  induration,  are  met  with,  which  are 
sometimes  gonorrhoeal,  but  generally  traumatic,  in  origin. 

Such  patients  have  usually  had  their  strictures  divided  by  ex- 
ternal urethrotomy  several  times,  but,  in  spite  of  the  regular  passage 
of  sounds,  they  contract  rapidl}',  and  it  is  impossible  to  keep  them 
open. 

A  conservative  method  of  dealing  with  such  cases  is  to  lay  bare 
the  urethra  and  excise  the  strictured  portion. 

This  was  first  done  by  Konig  in  1882,  who  cut  out  the  strictured 
portion  of  the  urethra  and  brought  the  separated  edges  again  into 
apposition  and  stitched  them  together.  In  1892  Guyon  and  Albarran 
resected  strictures  and  allowed  the  space  between  the  cut  ends  of  the 
urethra  to  fill  in  with  granulations. 

The  author  has  used  the  method  devised  by  Fuller  with  satis- 
factory results. 

Technique. — A  sound  is  introduced  through  the  meatus  and  the 
perineal  urethra  exposed  by  dissection.  If  the  bulbous  urethra  is  in- 
volved, the  scrotum  must  be  split  in  two  halves  in  order  to  lay  the 
urethra  bare.  The  strictured  portion  of  the  urethra  is  entirely  ex- 
cised with  curved  scissors,  with  the  exception  of  a  narrow  bridge  of 
urethral  tissue  one-quarter  of  an  inch  wide  on  the  roof. 


128  STRICTURE  OF  THE  URETHRA. 

A  large  catheter  is  inserted  at  the  lower  angle  of  the  perineal 
wound  to  drain  the  bladder,  and  a  No.  26  French  soft  catheter  is 
passed  through  the  meatus  and  perineal  urethra,  till  its  end  rests 
against  the  perineal  tube.  The  perineal  tissues  are  then  sewed  around 
the  urethral  tube  with  catgut,  thus  building  up  a  channel  which  will 
eventually  form  the  new  urethra. 

The  skin-edges  are  then  brought  together  with  superficial  su- 
tures, and,  if  the  scrotum  has  been  divided,  a  couple  of  deep  silk- 
worm-gut sutures  may  be  introduced. 

Both  tubes  may  be  removed  in  one  week,  but  a  sound  should  not 
be  passed  for  three  weeks. 


EXTRAVASATION  OF  URINE. 

Extravasation  of  urine  is  one  of  the  severest  and  most  dangerous 
complications  which  occurs  as  a  result  of  stricture.  It  is  by  no 
means  uncommon,  and  Sir  Henry  Thompson  found  it  occurring  8 
times  out  of  217  cases  of  stricture. 

In  its  attempts  at  evacuation  the  straining  and  pressure  of  the 
hypertrophied  bladder  cause  a  rupture  of  the  thin  walls  of  the 
pouch-like  dilatation  of  the  urethra,  lying  behind  the  stricture,  and 
the  urine  escapes  into  the  periurethral  cellular  tissue. 

A^Hien,  as  is  most  frequently  the  case,  the  rupture  occurs  in  front 
of  the  subpubic  ligament,  the  urine  burrows  through  the  cellular 
tissue  of  the  scrotum  and  penis  and  extends  upward  toward  the  hypo- 
gastrium. 

Abscess  rapidly  forms,  the  tissues  become  gangrenous  and 
slough,  and  spontaneous  evacuation  of  the  pus  and  urine  occurs,  with 
considerable  destruction  of  tissue,  leaving  urinary  fistulas.  The  sep- 
tic condition  is  always  very  pronounced,  and  such  patients  usually 
die  unless  an  operation  is  performed  promptly  after  the  rupture 
occurs. 

When  the  rupture  of  the  urethra  takes  place  posterior  to  the 
subpubic  ligament,  the  burrowing  of  urine  takes  place  in  a  different 
direction.  In  this  case  the  urine  cannot  make  its  way  forward 
through  the  cellular  tissue  of  the  penis,  but  it  burrows  under  the 
deep  layer  of  the  perineal  fascia  and  accumulates  in  the  prevesical 
space,  forming  a  swelling  above  the  symphysis.    From  this  point  it 


EXTRAVASATION  OF  URINE.  129 

extends  and  inflammatory  swelling  and  suppuration  of  the  connective 
tissue  within  the  abdomen  occurs  and  the  patient  dies  of  pyaemia. 


TREATMENT. 

Urinary  extravasation  demands  immediate  operation  in  order 
to  save  the  patient's  life  and  prevent  extensive  sloughing  and  loss 
of  tissue. 

An  external  urethrotomy  should  be  performed  and  the  bladder 
drained  through  a  catheter  in  order  to  prevent  further  escape  of 
urine  into  the  tissues.  At  the  same  time  the  collections  of  pus  and 
urine  in  the  tissues  should  be  opened  up,  drained  freely,  and  packed 
with  gauze. 

If  the  prostatic  urethra  was  ruptured  behind  the  subpubic  liga- 
ment and  extravasation  has  taken  place  into  the  prevesical  space,  the 
pus  and  urine  should  be  evacuated  by  means  of  a  suprapubic  cystot- 
omy. 


CHAPTER   X. 

URINARY  FEVER.  1 

Urinary  fever  is  also  spoken  of  as  urethral  fever  or  catheter 
fever,  and  may  be  defined  as  a  set  of  symptoms  of  which  chill  and 
fever  are  the  most  prominent,  generally  occurring  in  consequence 
of  a  traumatism  to  the  genito-urinary  tract.  It  occurs  in  two  forms: 
acute  and  chronic. 

Acute  Form. — Shortly  after  instrumentation  of  the  urethra  or 
bladder — i.e.,  passing  sounds,  dilatation,  urethrotomy,  or  cystoscopy 
— a  chill  occurs  lasting  half  an  hour  or  more  and  followed  by  fever, 
and  the  urinary  secretion  is  lessened  or  entirely  suppressed.  After 
a  few  hours  the  temperature  falls,  with  profuse  sweating,  the  kid- 
neys begin  to  secrete  freely  again,  and  the  urine  contains  abundant 
urates  and  sometimes  albumin. 

The  chronic  form  may  result  as  the  outcome  of  an  acute  attack 
or  may  be  developed  ins.idiously  without  attracting  the  "attention  of 
the  patient,  who  only  complains  of  malaise,  dyspepsia,  etc.  The 
course  of  the  fever  is  prolonged,  and  the  patient  loses  strength  and 
emaciates  and  is  often  mildly  delirious  at  night.  This  condition  is 
generally  combined  with  severe  cystitis  and  often  pyelitis,  and  in  the 
end  the  patient  succumbs  to  the  cachexia  induced  by  the  chronic 
poisoning. 

PROGNOSIS. 

Urinary  fever  is  a  serious  disease,  especially  in  old  men  or  with 
those  having  diseased  kidneys.  The  most  important  factor  in  the 
recovery  of  acute  cases  is  the  freedom  with  which  the  kidneys  secrete 
urine,  and,  when  the  kidneys  do  not  resume  their  function  after  an 
acute  attack  or  were  previously  diseased,  the  outlook  is  grave. 

ETIOLOGY. 

Urinary  fever  was  formerly  thought  to  be  due  to  the  shock  and 
disturbance  to  the  nervous  system,  attendant  upon  passing  an  instru- 
ment into  the  urethra,  and  this  view  is  still  held  by  many  authorities, 

'"Die  Stricturen  der  HanniJhre,"  by  H.  Wossidlo. 

(130)  '     . 


imiNARY  FEVER.  131 

but  it  is  generally  regarded  at  the  present  time  as  an  infectious  dis- 
ease which  is  brought  about  by  the  entrance  of  pathogenic  organisms 
into  the  blood-circulation,  through  wounds  or  lacerations  of  the 
urethra  or  bladder.  Among  various  other  organisms  the  bacterium 
coli  commune  plays  an  important  part  in  the  causation  of  urinary 
fever. 

Micro-organisms  are  introduced  into  the  blood-circulation  in  the 
following  ways: — 

(a)  The  sound  or  dilator  may  have  been  dirty  and  infected  with 
germs,  which  are  introduced  into  an  accidental  laceration  made  in 
the  mucous  membrane  by  the  instrument. 

(&)  The  instrument  was  clean,  but  the  urine  was  septic  and  con- 
tains micro-organisms  from  a  cystitis  or  pyelitis,  and  the  attack  of 
fever  follows  very  soon  after  the  first  passage  of  urine,  through  the 
urethra.  The  micro-organisms  in  the  urine  pass  into  the  blood 
through  an  accidental  laceration  in  the  mucous  membrane  and  occa- 
sion the  attack. 

(c)  When  instrument  and  urine  are  both  sterile,  pathogenic  or- 
ganisms may  be  already  existent  in  the  urethra,  lying  especially  in  the 
parts  heliind  a  stricture,  and  are  introduced  ■  into  the  circulation 
through  a  traumatism. 

The  course  of  the  fever  depends  upon  the  size  of  the  wound  and 
the  quantity  of  micro-organisms  absorbed.  If  a  small  amount  of 
septic  material  is  taken  up  in  oft-repeated  doses,  the  fever  runs  a 
chronic  course. 

In  case  the  kidneys  were  diseased  and  incapable  of  eliminating 
waste-products  completely,  before  the  onset  of  the  fever,  the  attack  is 
more  severe,  inasmuch  as  the  kidneys  fail  to  excrete  the  products  of 
nitrogenous  waste  and,  in  addition,  cannot  clear  the  blood  of  the  ac- 
cumulated toxins. 

TREATMENT. 
Prophylaxis. — In  order  to  avoid  urinary  fever  the  following  con- 
ditions are  necessary: — 

I.  Healthy  kidneys.  As  already  stated,  imperfect  elimination 
of  urea  predisposes  strongly  to  urinary  fever;  hence  it  is  important 
to  ascertain  that  the  kidneys  are  healthy  before  operating  on  the 
urethra. 

II.  Complete  asepsis  of  instruments  and  genito-urinary  tract. 
It  is  easier  to  secure  asepsis  of  instruments  (see  section  on  care  of 


122  STRICTURE  OF  THE  URETHRA. 

instruments)  than  to  sterilize  the  genito-urinary  tract.  A  good  deal 
can  be  accomplished  in  that  direction  by  irrigations  of  the  bladder 
and  urethra  before  instrumentation  with  either  boric  acid  or  salt 
solutions. 

The  urine  should  be  sterilized  by  the  administration  by  the 
mouth  of  salol,  gr.  x,  three  times  a  day,  or  urotropin,  gr.  viij,  three 
times  a  day. 

III.  All  instrumentation  should  be  made  with  the  utmost  gentle- 
ness to  avoid  causing  lacerations.  By  avoiding  any  tearing  of  the 
mucous  membrane  there  is  no  opportunity  for  micro-organisms  to 
make  their  way  into  the  blood-current  and  so  excite  the  fever. 

Treatment  of  the  Attack. — As  already  stated,  after  the  chill  the 
fever  subsides,  when  the  patient  breaks  out  into  a  profuse  sweat,  and 
the  indication,  therefore,  is  to  encourage  free  perspiration,  by  putting 
the  patient  to  bed,  surrounding  him  with  hot  bottles,  and  giving  a 
hot  drink. 

Phenacetin  is  useful  for  the  headache,  and  a  saline  cathartic 
should  be  given  the  next  day  to  complete  the  elimination  of  the 
toxin. 

The  chronic  form  of  urinary  fever  is  generally  accompanied  by 
cystitis,  and  here  the  indications  are  to  secure  free  drainage  of  the 
bladder  and  keep  it  clean  by  frequent  irrigations.  If  the  inflamma- 
tion has  extended  from  the  bladder  upward  through  the  ureters  and 
involved  the  kidneys,  the  indication  for  treatment  is  to  increase  the 
reduced  secretion  of  urine  to  the  normal  standard  again  by  means 
of  milk  diet  and  large  draughts  of  spring-water. 

Salol  and  Urotropin  should  be  given  as  urinary  antiseptics  and 
small  doses  of  quinine  are  useful  as  a  tonic. 


CARE  OF  URETHRAL  INSTRUMENTS. 

All  the  instruments  which  are  used  in  the  urethra  should  be 
perfectly  smooth  and  highly  polished,  since  any  roughness  upon  the 
surface  will  abraid  the  delicate  mucous  membrane  and  expose  the 
patient  to  the  dangers  of  septic  absorption  and  urinary  fever.  In- 
struments should  also  be  well  lubricated  before  introduction. 
A^aselin  is  most  comi^only  employed,  but  it  has  the  disadvantage  of 
coating  the  mucous  membrane  and  preventing  its  contact  with  irri- 


CARE  OF  URETHRAL  INSTRUMENTS.  I33 

gating  solutions  used  afterward.  Lubrichondrin  is  a  preparation 
made  from  Irish  moss,  is  slippery  and  soluble,  readily  washes  off, 
and  is  preferable  to  use.  Any  lubricant  should  be  kept  in  and  used 
from  the  flexible  tubes,  which  protect  it  from  the  air  and  keep  it 
sterile. 

Sounds  should  be  kept  in  a  drawer  and  prevented  from  knocking 
against  each  other,  as  that  destroys  the  polish,  and  after  using  they 
should  be  washed  with  a  piece  of  gauze  in  hot  water  with  soap. 
Afterward  they  ought  to  be  dipped  in  alcohol  as  far  as  the  handle 
and  flamed,  or  they  may  be  boiled  in  a  solution  of  washing  soda.^ 
The  soda  is  added  to  prevent  rusting.  Urethrotomes,  tunneled 
sounds,  lithotrites,  silver  catheters,  and  endoscopic  tubes  should  be 
scrubbed  with  a  brush  in  hot  water  with  soap  and  afterward  boiled 
in  soda  solution.  Soft-rubber  catheters  should  be  washed  off  outside 
and  running  water  allowed  to  flow  through  them;  but  this  is  not 
enough  for  disinfection,  and,  in  order  to  accomplish  this,  they  must 
be  boiled  in  plain  water  afterward. 

Flexible  gum-elastic  bougies  and  catheters,  filiform  guides,  and 
rubber-dilator  covers  and  cystoscopes  do  not  stand  boiling.  They 
can  be  disinfected  by  washing  with  gauze  and  soap  in  hot  water,  and 
exposing  afterward  to  the  vapor  of  formalin,  in  the  formalin  sterilizer 
(made  by  Schering  &  Glatz,  New  York). 

A  more  recent  method  of  sterilizing  gum-elastic  and  soft-rubber 
catheters  now  in  use  in  Berlin  is  to  immerse  them  in  the  following 
solution: — 

1}  Glycerin, 

Water    aa  8  ounces. 

Corrosive  sublimate 8  grains. 

After  six  hours'  immersion  laboratory  experiments  show  the 
catheter  to  be  sterile,  and  prolonged  exposure  of  the  instrument  in 
the  solution  does  not  roughen  or  crack  its  surfaces. 

Cystoscopes  may  be  kept  in  a  jar  filled  with  5-per-cent.  carbolic- 
acid  solution,  and  by  keeping  them  point  downward  with  the  eye- 
piece above  the  level  of  the  fluid  the  telescope  is  not  damaged. 

Knives  with  fine,  delicate  edges  are  dulled  by  boiling,  but  can 
be  sterilized  by  placing  in  alcohol  or  20-per-cent.  carbolic  solution  or 
in  the  formalin  sterilizing  cabinet. 


Flaming  is  to  be  preferred,  as  boiling  roughens  their  surfaces. 


DISEASES  OF  THE  BLADDER. 


CHAPTER   XL 

CYSTITIS. 

ETIOLOGY. 

It  is  an  event  of  great  rarity  for  a  perfectly  normal  bladder  to 
become  the  seat  of  inflammation,  while,  on  the  other  hand,  any 
non-inflammatory  affection  of  this  organ  is  most  apt  to  be  com- 
plicated, sooner  or  later,  by  the  element  of  germ-infection,  with  in- 
flammation ensuing. 

There  are  numerous  conditions  which  may  act  as  predisposing 
causes  to  cystitis,  although  they  may  exist  indefinitely  without 
actually  causing  inflammation.  The  one  most  frequently  met  with 
in  practice  is  the  retention  of  residual  urine,  occurring  in  cases  of 
stricture  and  enlarged  prostate  or  resulting  from  paralysis  of  the 
nerve-supply  to  the  bladder,  depending  upon  a  fractured  spine  or  a 
myelitis.  Eetention  of  urine  in  itself  cannot  cause  inflammation  so 
long  as  the  bladder  remains  free  from  infection  with  micro-organ- 
isms; but  stagnant  urine  affords  an  excellent  culture-medium  for 
the  growth  and  development  of  germs  which  may  be  introduced  into 
the  bladder,  and  the  retention  of  urine,  if  long  continued,  impairs  the 
vitality  of  the  mucous  membrane  by  keeping  it  congested. 

Chronic  congestion  of  the  rtnicous  membrane  may  occur  without 
the  presence  of  retained  urine,  and  may  be  occasioned  by  calculus, 
some  forms  of  prostatic  enlargement,  and  in  women  by  pregnancy 
and  menstruation. 

The  normal  epithelium  of  the  bladder  offers  a  barrier  to  the  pene- 
tration of  micro-organisms  so  long  as  its  cells  are  intact;  but  if  the 
bladder-walls  are  congested  for  some  time,  the  superficial  cells  are 
loosened  and  desquamated  and  the  softer  cells  underneath  are  ex- 
posed, allowing  the  entrance  of  germs. 

The  hyperemia  also  causes  the  small  blood-vessels  to  rupture, 
on  account  of  the  increased  vascular  pressure. 

Exposure  to  cold  is  often  considered  an  exciting  cause  of  cystitis, 
but  it  can  only  act  in  an  indirect  way  by  lowering  the  vitality  of 
the  tissues,  so  that  germ-infection  may  the  more  easily  take  place. 
(134) 


CYSTITIS.  135 

The  various  predisposing  causes  above  mentioned  cannot  in 
themselves  excite  inflammation.  They  operate  by  preventing  the 
bladder  from  being  evacuated  and  allowing  residual  urine  to  ac- 
cumulate and  form  a  favorable  culture-medium  for  germs,  or  by 
producing  congestion  of  the  mucous  membrane  which  lowers  its 
vitality  and  causes  desquamation  of  its  protective  cells,  thus  opening 
up  avenues  for  infection. 

The  exciting  cause  of  an  attack  of  cystitis  is  invariably  micro- 
organisms. Normal  urine  is  an  aseptic  fluid,  free  from  germs,  and 
can  be  injected  into  the  peritoneal  cavity  without  causing  suppura- 
tion. In  every  case  of  cystitis  various  forms  of  cocci  and  bacteria  are 
always  present. 

Many  of  these  organisms  are  incapable  of  causing  cystitis,  if  they 
find  their  way  into  a  normal  bladder,  which  can  be  completely  emptied 
of  its  urine,  because  they  are  voided  along  with  the  urine,  without 
causing  any  injury  to  the  bladder. 

On  the  other  hand,  the  staphylococcus  pyogenes  and  the  uro- 
bacillus  liquefaciens  septicus  and  virulent  cultures  of  the  bacillus 
coli  possess  the  power  of  breaking  up  urea  and  forming  ammonia, 
and  on  this  account  they  are  able  in  themselves,'  without  the  aid  of 
a  favorable  predisposing  cause,  to  excite  cystitis. 

Micro-organisms  Found  in  Cystitis. — C.  Mansell  Moullin^  ex- 
amined the  urine  from  30  cases  of  suppurative  cystitis,  most  of 
which  were  old  men  with  enlarged  prostates.  Cases  of  tubercular 
and  gonorrhoeal  cystitis  were  excluded,  and  the  following  results  were 
obtained: — 

The  Reaction  was  acid  or  neutral  in  2-i  and  alkaline  in  6. 

Micro-organisms  were  present  in  abundance  in  all  of  them. 

The  bacillus  coli  was  present  in  21  of  the  acid  urines  and  in  4 
of  the  alkaline  cases. 

Streptococcus  pyogenes  occurred  in  4  acid  and  in  3  alkaline 
cases. 

The  urobacillus  liquefaciens  was  present  in  5  of  the  alkaline 
cases. 

In  addition  a  staphylococcus  was  present  in  8  and  a  diplococcus 
in  2. 

These  examinations  show  that  the  bacillus  coli  is  the  organism 


'"Inflammation  of  the  Bladder  and  Urinary  Fever,"  Blakiston,  1898. 


136  DISEASES  OF  THE  BLADDER. 

most  frequently  present  in  cystitis  when  tlie  urine  is  acid,  and  the 
urobacillus  liquefaciens  septicus  when  it  is  alkaline. 

Bacillus  coli  in  shape  is  a  short  round  bacillus  with  rounded  ends 
which  is  found  normally  in  the  intestinal  canal.  The  virulence  of 
its  cultures  depends  upon  the  source  from  which  they  are  taken,  a 
growth  from  the  contents  of  the  healthy  intestine  having  less  viru- 
lence than  one  taken  from  a  case  of  infantile  diarrhoea,  while  a  cult- 
ure from  choleraic  discharges  is  virulent  in  the  highest  degree. 

Unlike  other  micro-organisms,  the  bacillus  coli  has  but  little 
effect  in  causing  the  urine  to  become  alkaline  by  decomposing  its 
urea,  and  the  urine  retains  its  acid  reaction  for  a  considerable  length 
of  time.  Although  the  bacillus  coli  is  a  harmless  saprophyte  in  the 
intestine,  it  has  the  effect,  when  injected  into  the  tissues,  of  causing 
an  abscess  or  of  inducing  toxaemia  or  general  septicsemia. 

The  urobacillus  liquefaciens  septicus  is  chiefly  of  interest  from 
its  power  of  decomposing  urea  and  causing  the  urine  to  become  alka- 
line within  a  few  hours. 

Cultures  of  the  bacillus  coli,  if  injected  into  the  bladder,  often 
fail  to  produce  cystitis  unless  a  predisposing  cause,  such  as  retention 
of  urine  or  congestion,  be  present. 

If,  however,  the  urobacillus  gains  admission  to  the  bladder, 
cystitis  almost  invariably  follows  on  account  of  the  ammonia  which 
is  set  free  from  the  decomposed  urea  and  which  acts  as  an  exciting 
cause  for  the  inflammation. 

The  streptococcus  pyogenes  and  staphylococcus  pyogenes  aureus 
are  both  capable  of  inducing  septicaemia  if  they  gain  entrance  into 
the  blood-circulation,  and  locally  they  attack  the  bladder-^talls,  caus- 
ing diffuse  inflammation  with  suppuration. 

The  streptococcus  does  not  decompose  urea,  and  when  it  is  found 
in  alkaline  urine  the  decomposition  has  been  effected  through  the 
agency  of  another  micro-organism,  which  is  often  the  urobacillus. 

Experimental  and  clinical  evidence  serves  to  show  that,  while 
all  cases  of  ordinary  suppurative  cystitis  are  dependent  upon  these 
or  similar  organisms,  inflammation  of  the  bladder  cannot  be  induced 
by  their  mere  introduction  into  it,  so  long  as  the  urine  can  be  com- 
pletely evacuated  and  its  walls  are  in  a  healthy  condition.  The  uro- 
bacillus liquefaciens  alone  is  capable  of  exciting  cystitis  in  a  normal 
bladder,  through  its  property  of  decomposing  urea. 

If,  however,  there  be  residual  urine  retained  in  the  bladder,  be- 
hind a  stricture  or  enlarged  prostate,  or  if  the  bladder-wall  is  con- 


CYSTITIS. 


137 


gested  and  eroded  from  the  irritation  of  a  calculus  or  the  administra- 
tion of  cantharides,  cystitis  will  surely  result  from  the  introduction 
of  the  other  forms  of  micro-organisms. 

Avenues  Through  which  Micro-organisms  Reach  the  Bladder.— 
Germs  may  enter  the  bladder  by  the  following  routes: — 

I.  Through  the  urethra. 

II.  They  may  descend  with  the  urine  from  the  kidneys. 

III.  They  may  pass  through  the  blood-circulation  direct  to  the 
bladder. 

IV.  They  may  pass  through  the  lymphatics  from  adjacent 
organs. 

/.  Infection  Through  the  Urethra. — As  already  stated,  the  bacil- 
lus coli  is  responsible  for  the  larger  number  of  cases  of  cystitis.  Its 
chief  habitat  is  the  intestine,  where  it  is  always  present,  although 
varying  greatly  in  virulence.  It  is  also  usually  to  be  found,  but 
mixed  with  other  organisms,  upon  the  glans  penis  and  under  the 
prepuce  and  in  the  fossa  navicularis,  and  in  women  it  exists  in  the 
meatus  urinarius  and  the  folds  of  the  vulva. 

The  deep  urethra  in  the  male  probably  does  not  afford  a  resting- 
place  for  germs  while  it  is  healthy.  When,  however,  it  is  altered  by 
disease,  either  stricture  or  enlargement  of  the  prostate,  the  dilated 
pouch,  containing  stagnant  urine  and  mucus,  affords  a  favorable 
hibernating-place  for  bacteria. 

Cystitis  does  not  occur  in  men  with  healthy  urethras,  except 
as  a  result  of  instrumentation,  but  in  cases  of  enlarged  prostate  it  is 
of  common  occurrence,  even  when  no  instruments  have  been  used. 
In  most  instances  where  the  bladder  is  infected  from  the  urethra  a 
catheter  or  sound  is  the  means  by  which  the  germs  are  introduced. 

Although  the  instrument  may  have  been  sterile  before  intro- 
duction, it  may  have  been  infected  by  brushing  against  the  patient's 
clothing  or  acquired  germs  from  contact  with  the  glans  penis  or 
meatus,  or  it  may  have  carried  germs  along  from  a  pouch  behind  a 
stricture  or  enlarged  prostate  in  the  urethra  itself. 

But,  unless  the  predisposing  causes  of  congestion  of  the  bladder- 
wall  or  residual  urine  be  present,  the  micro-organisms  will  usually  be 
swept  out  of  the  bladder  with  the  first  act  of  urination,  without 
causing  any  damage. 

II.  Infection  of  the  Bladder  with  Bacteria  which  Descend  in  the 
Urine  from  the  Kidneys. — The  bacillus  coli,  which  exists  in  profusion 
in  the  intestinal  canal,  readily  makes  its  way  through  the  wall  of 


138 


DISEASES  OF  THE  BLADDER. 


the  intestine,  into  the  blood-circulation  and  notably  so,  if  diarrhoea 
or  intestinal  disease  be  present.  After  gaining  the  blood-circulation 
the  bacilli  are  eliminated  by  the  kidneys,  and  passing  out  with  the 
urine  gain  entrance  into  the  bladder,  and  under  the  existence  of 
favoring  conditions,  such  as  congestion  or  residual  urine,  cystitis  is 
excited. 

III.  Infection  of  the  Bladder  Through  the  Blood-current.  —  In- 
fective emboli  occurring  in  the  course  of  some  general  disease  may 
be  carried  through  the  capillaries,  and  local  foci  of  disease  in  the 
bladder  may  be  originated  through  their  agency.  This  cause  of  in- 
fection, however,  seldom  occurs  except  as  a  result  of  tuberculosis. 

IV.  Micro-organisms  Formed  in  an  Adjacent  Organ  may  he  Car- 
ried to  the  Bladder  Through  the  Channel  of  the  Lymphatic  Vessels. — 
This  form  of  infection  has  been  proved  experimentally  and  will  serve 
to  explain  the  occurrence  of  cystitis  in  women  who  are  the  subjects 
of  salpingitis  and  endometritis  and  in  whom  the  micro-organisms 
probably  pass  from  the  ovaries  or  uterus  to  the  blad'der,  through  the 
lymphatics. 

CLASSIFICATION. 

Cystitis  begins  acutely,  and  frequently  becomes  chronic.  Vari- 
ous attempts  to  group  the  varieties  from  an  etiological  or  anatomical 
stand-point  have  been  made,  but  for  practical  uses  a  division  into 
simple,  suppurative,  and  specific  cystitis  serves  the  purpose. 

Under  the  term  simple  cystitis  is  understood  the  inflammation 
of  the  bladder  which  is  not  caused  by  germ-infection,  but  which 
results  from  a  mechanical  cause,  such  as  the  irritation  from  a  cal- 
culus or  crystals  in  the  urine  or  from  a  chemical  irritation  caused  by 
cantharides.  Simple  cj-stitis  exists  as  a  theoretical  condition  only,  for, 
as  a  matter  of  fact,  the  complication  of  germ-infection  occurs  in  every 
case,  and  in  a  few  hours  the  bladder  becomes  infected  with  micro- 
organisms, and  the  simple  inflammation  is  converted  into  suppurative 
cystitis. 

PATHOLOGICAL  CHANGES  IN  THE  BLADDER. 

Locatioii. — The  disease  process  is  most  marked  in  the  region  of 
the  trigone  and  particularly  so  around  the  ureters  and  urethral 
orifice.     The  fundus  is  usually  nearly  or  quite  normal. 

The  mucous  membrane  is  the  part  usually  affected,  but  the  in- 


CYSTITIS.  139 

flammation  may  attack  the  deeper  structures  and  the  muscular,  sub- 
serous, and  even  the  serous  coats  may  be  involved. 

In  acute  cystitis  the  cystoscope  affords  a  means  of  studying  the 
changes  in  the  mucous  membrane  of  the  bladder.  Its  color  is  found 
to  be  brilliant  scarlet,  with  branching  lines  marking  the  course  of 
the  distended  vessels,  which  bleed  readily.  The  surface  of  the 
mucous  membrane  has  lost  its  polish,  is  ragged  and  velvet}^,  and  has 
flakes  of  lymph  adhering  to  it.  In  severe  cases  the  epithelium  is 
detached,  leaving  erosions. 

In  very  septic  cases  portions  of  the  mucous  membrane  slough 
away,  and  hang  from  the  walls  in  shreds,  and  minute  abscesses  may 
form  in  the  submucous  coat  or  among  the  muscular  layers.  Micro- 
organisms are  invariably  present;  the  urine  is  filled  with  them  and 
they  lie  on  the  surface  and  between  the  epithelial  cells. 

The  pathological  changes  in  chronic  cystitis  resem-ble  those  of 
the  acute  form,  but  are  more  marked.  The  erosions  are  deeper, 
sometimes  forming  actual  ulcers.  The  surface  of  the  mucous  mem- 
brane is  black  or  slate  colored,  from  the  escape  of  blood-pigment  into 
the  tissues  through  small  capillary  ruptures. 

In  the  early  stages  the  muscular  coat  may  undergo  a  true  hyper- 
trophy of  its  fibres,  but,  as  a  rule,  the  prolonged  inflammation  and 
the  vascular  degeneration  lead  in  time  to  a  condition  of  fibroid  in- 
duration and  sclerosis  of  the  bladder-wall.  The  walls  are  thicker 
and  denser  than  normal  and  their  elasticity  is  entirely  lost.  As  a 
result  of  those  conditions  the  cavity  of  the  bladder  often  becomes  so 
small  and  contracted  that  it  can  only  hold  a  few  ounces.  The 
bladder-wall  on  contracting  falls  into  folds,  with  spaces  between 
them,  from  which  it  is  difficult  to  empty  the  urine  even  with  a 
catheter. 

In  time  the  spaces  become  stretched,  forming  sac-like  dilatations, 
which  may  be  as  large  as  the  bladder  itself. 

These  sacs  are  only  covered  by  serous  membrane,  and  have  no 
muscular  fibres;  so  that  they  cannot  empty  themselves  of  their  con- 
tained urine,  and,  filled  with  stagnant  decomposing  urine,  they  be- 
come a  favorite  seat  for  stone-formation. 

On  the  other  hand,  the  bladder-walls,  instead  of  being  hard  and 
fibrous  around  a  small  contracted  cavity,  may  become  thin  and 
flaccid,  and  the  cavity  may  be  distended  to  a  capacity  of  a  quart  or 
more. 

Membranous  Cystitis. — As  a  result  of  intense  septic  infection  of 


140 


DISEASES  OF  THE  BLADDER. 


Fig.  48. — Formation  of  a  Sacculation  in  a  hypertrophied  Bladder  from 
Prostatic  enlargement  and  prolonged  Cystitis. 

the  bladder,  combined  with  pressure  on  its  blood-vessels,  sufficient 
to  shut  off  the  circulation  and  cause  gangrene,  a  false  membrane  may 
form  within  the  bladder,  which  is  thrown  off  as  a  coat  of  its  walls. 

The  microscope  shows  these  coats  to  be  composed  of  epithelial 
cells,  lymph,  urinary  salts,  and  micro-organisms  entangled  together. 

The  slough  may  make  its  exit  through  the  urethra  or  the  whole 
thickness  of  the  bladder-wall  may  slough  into  the  cavity  of  the  abdo- 
men. 


SYMPTOMS. 

local  Symptoms. 

I.  Frequent  TJrinaticn. — The  inflamed  and  irritable  condition 
of  the  bladder-walls  and  posterior  urethra  renders  the  bladder  very 
intolerant  of  any  tension  and  after  a  small  quantity  of  urine  collects 
it  is  expelled.  Prolonged  standing  or  jolting  increases  the  desire  to 
urinate  in  cystitis  and  particularly  so  when  the  inflammation  depends 
upon  a  vesical  calculus. 

II.  Painful  "Urination. — In  acute  cases  the  pain  is  more  or  less 
constantly  present  over  the  bladder,  and  is  aggravated  by  the  act  of 
urination.     As  the  desire  to  urinate  comes  on,  the  pain  increases. 


CYSTITIS.  141 

and  as  the  bladder  contracts  the  pain  may  be  agonizing,  and  is  felt 
in  the  bladder  and  rectum,  and  radiates  to  the  end  of  the  penis  and 
down  the  thighs. 

In  severe  cases  there  is  a  desire  to  nrinate  every  few  minutes, 
and  the  act  of  urination  is  accompanied  by  great  straining  or 
tenesmus. 

In  the  presence  of  stone  or  posterior  urethritis  of  gonorrhoeal 
origin  the  pain  is  increased  after  the  act  of  urination,  on  account  of 
the  inflamed  walls  of  the  bladder  being  squeezed  together  by  the 
muscular  contractions.  Strangury  is  noted  in  the  most  severe  cases 
only,  in  which  the  pain  is  continuous  and  where  the  patient  makes 
violent  and  straining  efforts  to  urinate  and  only  expels  a  few  drops 
of  blood-stained  urine  each  time. 

In  chronic  cases  but  little  pain  is  experienced,  except  in  the 
instances  of  enlarged  prostate,  when  the  bladder  is  hypertrophied 
and  very  much  contracted. 

III.  Pyuria. — Pus  in  the  urine  is  a  constant  occurrence  in  every 
case  of  cystitis.  If  the  urine  is  acid  in  reaction  the  pus  appears  as 
a  cloud  distributed  through  the  urine,  but  if  reaction  is  alkaline  and 
ammoniacal,  the  pus  is  coagulated  and  takes  the  form  of  a  viscid, 
tenacious,  ropy  mass,  at  the  bottom  of  the  vessel. 

IV.  Hasmaturia. — A  slight  amount  of  bleeding  occurs  from  a 
rupture  of  the  congested  capillaries  in  the  bladder-walls,  in  all  cases 
of  cystitis.  The  blood  is  always  intimately  mixed  with  the  urine  and 
disseminated  through  it.  A  gush  of  pure  blood  following  the  act 
of  urination  is  a  characteristic  sign  of  inflammation  of  the  posterior 
urethra. 

Constitutional  Symptoms. 

The  constitutional  symptoms  in  cystitis  are  caused  by  the  toxins 
which  are  absorbed  into  the  circulation,  and  their  severity  depends 
upon,  first,  the  amount  of  the  poison  absorbed  and,  secondly,  upon 
the  rapidity  of  its  absorption. 

If  the  bladder  is  able  to  empty  itself  thoroughly,  absorption 
does  not  take  place  to  any  great  extent  and  the  constitutional  dis- 
turbance is  not  marked. 

If,  on  the  other  hand,  the  bladder  cannot  evacuate  itself  com- 
pletely or  if  pyogenic  organisms  have  invaded  its  walls,  severe  con- 
stitutional disturbance  follows. 

In  acute  cystitis  the  bladder  can  usually  empty  itself,  and  the 


142 


DISEASES  OF  THE  BLADDER. 


temperature  is  not  high  and  the  constitutional  symptoms  are  not 
particularly  marked;  but  if,  from  some  cause,  obstimction  to  the 
outflow  of  urine  exists,  and  the  protecting  epithelium  has  been  des- 
quamated from  the  bladder-wall,  an  opportunity  for  the  absorption 
of  toxins  is  afforded  and  the  constitutional  symptoms  are  grave. 

This  is  particularly  true  in  cases  of  mixed  infection,  in  which 
the  bacillus  coli  is  associated  with  the  urobacillus  liquefaciens  septi- 
cus  or  staphylococcus  pyogenes. 

The  ammonia  which  is  formed  from  the  decomposed  urea  helps 
to  break  down  the  protecting  layer  of  bladder  epithelium,  and  the 
erosions  thus  formed  allow  large  quantities  of  toxins  to  pass  rapidly 
into  the  blood-circulation. 

In  old  men  at  the  beginning  of  catheter-life  an  asthenic  form  of 
cystitis  is  not  uncommon.  It  is  always  associated  with  chronic 
urinary  fever  and  is  often  fatal. 

In  chrome  cystitis  the  constitutional  disturbance  is  slight  be- 
cause there  is  very  little  absorption  of  toxins  from  the  bladder. 
Grave  symptoms  occur  only  when  an  acute  attack  is  ingrafted  upon 
a  bladder  which  has  suffered  with  chronic  inflammation.  Some  or- 
ganism which  is  capable  of  decomposing  urea  enters  and  ammonia  is 
formed.  The  tissues,  altered  by  long-continued  inflammation,  re- 
spond violently  to  the  irritant,  the  kidneys  become  involved,  and 
septic  poisoning  follows. 


DIAGNOSIS. 

The  symptoms  of  frequent  urination  and  pain,  when  accom- 
panied by  turbidity  of  the  urine  from  pus  and  occasionally  blood, 
are  very  characteristic  of  cystitis.  The  presence  of  pus  or  blood  in 
the  urine,  however,  only  signifies  that  there  is  a  condition  of  suppura- 
tion somewhere  along  the  genito-urinary  tract.  In  chronic  cases 
of  cystitis  it  is  always  important  to  exclude  such  local  conditions  as 
stricture,  stone,  or  enlarged  prostate,  and  in  amite  cases  the  absence 
of  gonorrhoeal  or  tubercular  infection  should  be  ascertained  and 
the  state  of  the  prostate  and  seminal  vesicles  should  always  be 
examined. 

The  use  of  the  cystoscope  is  not  admissible  in  acute  cases,  on 
account  of  its  increasing  the  existing  irritation,  but  in  chronic  cysti- 
tis it  is  indispensable.  By  its  means  it  is  possible  to  exclude  malig- 
nant disease  and  tuberculosis  of  the  bladder  and  calculus,  and  the 


CYSTITIS.  143 

presence  or  absence  of  an  enlarged  and  projecting  middle  lo'be  of  the 
prostate  can  be  readily  ascertained. 

P3^elitis  can  at  the  same  time  be  diagnosed  or  excluded,  some- 
times from  the  appearance  of  the  ureteral  openings,  but  with  abso- 
lute certainty  by  catheterizing  the  ureters. 

The  microscopic  examination  is  almost  as  important,  to  deter- 
mine the  character  of  the  micro-organisms,  the  variety  of  the  urinary 
crystals,  and  the  form  of  the  epithelial  cells,  from  which  some  con- 
clusion as  to  the  involvement  of  the  kidneys  may  be  drawn. 

PROGNOSIS. 

Acute  cystitis  may  heal  completely  or  it  may  become  chronic. 

The  cure  of  chronic  cystitis  depends  entirely  upon  its  causation. 
When  it  is  due  to  stone,  stricture,  or  enlarged  prostate,  and  its  cause 
can  be  removed  by  surgical  interference,  the  prognosis  is  good. 

Chronic  cystitis  in  itself  rarely  causes  death  except  in  the  aged 
and  debilitated,  who  die  from  absorption  of  toxins  and  urinary  fever; 
but,  if  inflammation  of  the  bladder  continues  for  some  time,  the  in- 
fection travels  up  the  ureters,  and  the  kidneys  become  the  seat  of 
disease  which  ultimately  proves  fatal. 

PREVENTIVE  TREATMENT. 

Suppurative  cystitis  is  always  caused  by  micro-organisms,  of 
which  the  most  common  form  is  the  bacillus  coli  communis,  which 
originates  in  the  intestine  and  may  make  its  way  into  the  bladder 
through  the  urethra,  general  blood-circulation,  or  lymphatics. 

Under  ordinary  conditions  the  bacillus  coli  is  a  harmless  sapro- 
phyte, but  diarrhoea,  constipation,  and  other  intestinal  disorders 
convert  it  into  an  extremely  virulent  pyogenic  germ.  Hence  it  fol- 
lows that  the  intestinal  canal  should  be  kept  as  aseptic  as  possible 
by  means  of  calomel,  purgatives,  and  intestinal  antiseptics.  Local 
foci  of  infection,  where  germs  can  grow  in  the  urethra  and  around 
the  external  genitals  of  the  male  and  female,  should  be  kept  clean 
and  aseptic. 

As  long  as  the  mucous  membrane  lining  the  bladder  remains 
unbroken  and  the  organ  is  capable  of  being  completely  emptied  of 
its  contained  urine,  bacteria  may  be  introduced  into  the  bladder 
without  harm,  as  they  are  soon  flushed  out  by  the  stream  of  urine, 
and  cystitis  can  rarely  be  induced  unless  the  bladder-wall  has  been 


244  DISEASES  OF  THE  BLADDER. 

congested  and  the  epithelial  lining  eroded  or  it  contains  residual 
urine,  caused  by  an  enlarged  prostate,  stricture,  or  vesical  atony.  On 
this  account  it  is  important  to  attend  to  any  local  diseased  conditions 
which  interfere  with  its  proper  emptying,  and  allow  residual  urine 
to  accumulate  or  the  bladder-walls  to  become  congested  and  eroded. 
Catheters  and  sounds  must  be  sterile  before  using,  and  the  ex- 
ternal genitals  should  always  be  cleansed  before  instrumentation  (see 
section  on  asepsis  of  instruments). 

GENERAL  TREATMENT  OF  ACUTE  CYSTITIS. 

In  all  but  the  mildest  cases  the  patient  should  be  kept  in  bed 
until  the  severity  of  the  symptoms  is  controlled  and  the  acute  stage 
is  past. 

The  room  should  be  maintained  at  an  even  temperature,  for  the 
congestion  of  an  inflamed  bladder  is  notably  increased  by  chilling 
the  surface  of  the  body  and  by  the  muscular  efforts  of  walking. 

Purgatives. — A  brisk  calomel  purge  should  always  be  adminis- 
tered at  the  beginning  of  an  attack  for  the  purpose  of  clearing  out 
the  intestine,  which  is  the  main  source  from  which  the  bacillus  coli 
is  derived.  It  has  been  shown  experimentally  that  rectal  obstruction 
is  almost  immediately  followed  by  the  appearance  of  enormous  num- 
bers of  colon  bacilli,  which  come  either  from  the  kidneys  or  directly 
from  the  rectum  to  the  bladder  through  the  thin  intervening  walls. 
During  the  progress  of  the  case  a  daily  movement  of  the  bowels 
should  be  secured  by  Hunyadi  or  Eubinat  water. 

Hot  sitz-baths  at  a  temperature  of  100°  or  105°  P.  are  service- 
able in  allaying  the  vesical  irritability  and  tenesmus.  The  exposed 
part  of  the  patient's  body  should  be  well  covered  with  blankets  while 
taking  them. 

The  diet  should  be  light  and  largely  composed  of  milk.  Meat 
should  not  be  allowed  at  all  or  only  in  small  quantities.  Fresh  fruit 
may  be  taken  in  moderation.  Alcohol  is  interdicted  unless  perhaps 
in  old  men  who  need  a  stimulant,  in  which  case  whisky  well  diluted 
may  be  used. 

Diluents.  —  Pure  spring-water  or  distilled  water  may  be  taken 
freely,  unless  the  desire  to  urinate  is  very  frequent  and  urgent.  The 
various  infusions  of  triticum,  buchu,  etc.,  probably  render  the  urine 
bland,  simply  through  the  water  they  contain.  Alkalies  should  never 
bo  administered  as  a  routine  measure,  since  in  cystitis  the  urine  is 
frequently  alkaline  from  decomposition  of  urea  into  ammonia  or  from 


CYSTITIS.  145 

ca  fixed  alkali,  and  the  internal  use  of  alkalies  do  harm  by  increasing 
the  alkalinity.  If  the  urine  is  highly  acid  and  deposits  uric-acid  crys- 
tals, bicarbonate  or  citrate  of  potash  is  useful  in  allaying  the  irritation. 

Opium  is  often  required  in  acute  cases  to  control  the  vesical  tenes- 
mus, pain,  and  irritability.  It  is  given  preferably  in  ^/o-grain  morphia 
suppositories,  but  may  be  used  by  the  mouth  as  well.  It  is  unwise  to 
inject  morphia  into  the  bladder.  If  the  bladder  mucous  membrane 
is  unbroken,  it  will  not  be  absorbed,  and,  if  erosions  are  present, 
absorption  may  occur  too  quickly,  and  give  rise  to  symptoms  of 
poisoning. 

The  same  holds  true  of  cocaine,  which  has  little  or  no  effect  in 
causing  local  anaesthesia  of  the  bladder,  as  it  does  in  other  mucous 
membranes,  and  has  the  great  disadvantage  of  very  materially  increas- 
ing the  congestion  of  the  mucous  membrane,  at  times  sufficiently  to 
cause  retention  of  urine. 

Balsams. — Sandal-wood  oil  has  a  very  beneficial  action  in  allaying 
the  too  frequent  urination  and  pain  of  cystitis,  in  its  acute  stage. 
Later  in  the  attack,  when  the  secretion  of  pus  has  diminished  so  that 
the  urine,  instead  of  being  turbid,  presents  only  a  fine  cloudiness,  the 
oleoresins,  such  as  turpentine,  copaiba,  cubebs,  and  fluid  extract  of 
pichi,  and  minute  doses  of  cantharidin  dissolved  in  alcohol,  have  an 
effect  in  quickly  causing  a  cessation  of  the  suppuration  and  a  clearing 
up  of  the  urine. 

Urinary  Antiseptics.  —  The  antiseptics  are  supposed,  through 
their  germicidal  properties,  to  destroy  the  inflammatory  process  at  its 
root.  Salol  may  be  considered  as  a  representative  of  the  group.  It  is 
given  in  doses  of  gr.  x  three  times  a  day,  and  acts  promptly  as  a  de- 
stroyer of  micro-organisms,  through  the  constituent  carbolic  acid, 
which,  from  its  decomposition,  is  set  free  in  the  urine.  In  the  same 
way  boric  and  benzoic  acids,  in  doses  of  20  grains  per  day,  exercise 
their  germicidal  power,  and  are  to  be  chosen  when  the  urine  is  alka- 
line in  reaction  from  the  presence  of  a  fixed  alkali. 

In  the  group  of  aniline  derivatives  may  be  mentioned  methyl- 
blue  and  Urotropin.  Methyl-hlue,  first  recommended  by  Einhorn,  in 
the  quantity  of  15  grains  a  day  in  tablets  or  capsules,  is  often  of  service 
when  the  urine  contains  large  quantities  of  bacteria.  The  urine,  from 
using  this  drug,  becomes  greenish  at  first  in  color  and  later  of  an  in- 
tense blue.  Urotropin,  which  dissolves  phosphatic  concretions  and 
causes  phosphaturia  to  disappear  with  rapidity  and  often  perma- 
nently, in  many  cases,  has  proved  to  be  a  urinary  antiseptic  of  great 


146 


DISEASES  OF  THE  BLADDER. 


value,  and  particularly  so  in  cases  of  chronic  cystitis  accompanied  by 
ammoniacal  decomposition  of  urine.  It  does  not  destroy  the  micro- 
organisms, but  prevents  their  growth  and  development.  The  proper 
dose  is  24  grains  per  day;  if  this  is  exceeded,  burning  in  the  urethra 
and  frequent  urination  occur. 


LOCAL  TREATMENT  OF  ACUTE  CYSTITIS. 

Bladder-washing,  which  is  so  essential  in  chronic  cases,  is  entirely 
inadmissible  in  the  acute  forms.  The  only  varieties  of  local  applica- 
tion which  can  be  used  without  doing  harm  are: — 

Instillations  of  Nitrate  of  Silver. — These  can  be  used  with  advan- 
tage in  the  most  acute  cases  of  cystitis.  The  principal  indications  for 
their  use  are  painful  and  frequent  urination,  provided  the  bladder  is 
capable  of  emptying  itself.  By  means  of  an  Ultzmann  syringe  20 
drops  of  nitrate-of-silver  solution,  increasing  in  strength  from  gr.  j 
to  gr.  X,  are  deposited  every  second  or  third  day  in  the  posterior  ure- 
thra, from  which  point  it  flows  back  into  the  bladder  and  trickles  over 
the  surface  of  the  trigone,  which,  together  with  the  posterior  urethra, 
are  the  parts  most  involved  in  the  inflammatory  process.  The  bladder 
should  be  empty,  before  the  instillation,  as  the  nitrate  of  silver  is  neu- 
tralized if  it  comes  in  contact  with  urine.  Instillations  are  mainly 
useful  in  acute  cases,  although  sometimes  of  service  in  chronic  cystitis. 


GENERAL   TREATMENT   OF   CHRONIC   CYSTITIS. 

After  the  severe  pain  and  frequent  urination  of  the  acute  stage 
have  passed  off,  the  urine  still  contains  pus  in  large  quantities  and 
has  to  be  voided  more  frequently  than  in  the  normal  condition. 

The  patient  should  no  longer  be  confined  to  bed,  but  should 
have  the  benefit  of  the  fresh  air,  although  much  walking  is,  of  course, 
out  of  the  question  for  him.  He  should  be  instructed  to  clothe  the 
body  in  flannel,  to  wear  woolen  stockings,  and  India  rubbers  in  damp 
weather,  and  cautioned  particularly  to  avoid  exposure  to  a  draft  or 
dampness. 

The  sandal-wood  oil  is  of  less  use  in  chronic  cases  than  in  the 
acute,  but  the  oleoresins  are  of  value;  and  the  urinary  antiseptics, 
Urotropin  and  salol,  have  here  their  field  of  greatest  usefulness.  By 
means  of  the  general  treatment  but  little  can  be  accomplished,  and 
the  main  reliance  is  the  local  treatment. 


CYSTITIS.  147 

LOCAL  TREATMENT  OF  CHRONIC  CYSTITIS. 

Indications. — I.  Eemove  any  local  source  of  irritation  within  the 
bladder  or  any  obstacle  to  its  evacuation.  Palliative  measures  for  the 
cure  of  cystitis  are  of  no  avail  if  a  calculus  or  tumor  be  allowed  to 
remain  within  the  bladder,  or  a  stricture  or  enlarged  prostate  causes 
residual  urine  to  accumulate. 

Indication  II.  Remove  the  urine  from  the  Madder  and  keep  it 
am  ply. 

In  cystitis,  if  the  bladder  is  able  to  empty  itself  completely,  the 
micro-organisms  are  soon  swept  away  and  the  attack  is  over;  but,  if 
residual  urine  is  allowed  to  remain  and  become  stagnant,  it  affords  an 
excellent  culture-medium  for  the  growth  of  the  germs. 

The  simplest  form  of  drainage  of  the  bladder  is  by  means  of  a 
soft-rubber  catheter  passed  once  a  day  or  oftener,  as  needed;  but  in 
atonic  bladders,  or  severe  cases,  this  is  not  sufficient;  but  the  bladder 
must  he  I'ept  empty. 

Permanent  catheterization  may  be  employed  by  passing  a  catheter 
into  the  bladder  through  the  urethra  and  tying  it  in,  so  that  the  urine 
is  voided  as  fast  as  it  is  secreted  by  the  kidneys.  The  disadvantages 
of  this  method  are  that  after  a  few  days  it  is  apt  to  excite  inflamma- 
tion of  the  urethra,  epididymitis,  urinary  fever,  or  suppression  of 
urine.  In  consequence  of  these  drawbacks,  except  in  very  light  cases 
of  cystitis  or  in  the  presence  of  debility  which  is  so  great  that  there  is 
danger  in  giving  an  anassthetic,  it  is  best  to  drain  the  bladder  through 
a  perineal  or  suprapubic  incision. 

Perineal  Drainage. — Technique  of  Operation. — A  lithotomy-staff 
is  introduced  into  the  bladder  through  the  urethra  and  an  incision  is 
made  through  the  perineum,  into  the  membranous  urethra,  by  thrust- 
ing a  long,  straight  bistoury  three-fourths  of  an  inch  in  front  of  the 
anus,  until  its  point  strikes  the  groove  in  the  staff.  A  gorget  is  intro- 
duced into  the  bladder  through  the  wound  and  a  No.  30  French,  soft- 
rubber  catheter  carried  along  it,  till  its  eye  lies  within  the  cavity  of 
the  bladder. 

A  silk  suture  is  then  passed  through  the  skin  of  the  perineal 
wound  and  the  catheter,  in  this  way  keeping  the  catheter  from  being 
forced  out  by  the  contractions  of  the  bladder. 

Instead  of  a  rubber  catheter,  Watson's  silver  perineal  drainage- 
tube  may  be  used  in  cases  where  the  bladder  is  tolerant;  but  the  metal 
tube  is  apt  to  excite  more  pain  than  the  soft-rubber  catheter. 

The  catheter  is  attached  to  a  rubber  tube  whose  end  lies  in  a 


248  •   DISEASES  OF  THE  BLADDER. 

bottle  on  the  floor  to  receive  the  urine.  In  this  way  the  bladder  is 
kept  entirely  empt)',  and  can  be  thoroughly  cleansed  by  irrigations. 

The  length  of  time  during  which  drainage  is  to  be  maintained 
varies  greatly,  depending  upon  the  degree  of  the  cystitis.  It  should 
be  continued  until  the  urine  is  free  from  pus  and  acid  in  reaction  and 
the  muscular  walls  of  the  bladder  have  regained  their  tone,  and  this, 
in  a  severe  case  of  long  standing,  may  require  some  months. 

Suprapubic  drainage  is  to  be  preferred  to  drainage  through  the 
perineum,  when  it  is  continued  for  some  length  of  time,  as  the  flow  of 
urine  through  the  abdominal  fistula  can  be  received  in  a  rubber  bag 
under  the  patient's  clothing  (the  Bloodgood  bladder-drain)  and  he  can 
go  about  and  keep  dry. 

The  operative  treatment  is  resorted  to  only  in  particularly  severe 
cases,  which  on  account  of  extreme  tenderness  make  all  local  means 
of  treatment  impossible.  Such  instances  occur  in  patients  with  con- 
tracted bladders  and  but  little  residual  urine.  They  suffer  from  con- 
stant pain  and  frequent  and  painful  urination,  with  the  discharge  of 
a  few  drops  of  ammoniacal  urine  each  time.  Again,  in  inveterate 
cases  of  chronic  cystitis,  where  the  bladder  is  atonic  and  perhaps  sac- 
culated, and  where  bladder-washing  and  instillations  have  been  used 
without '  effect,  permanent  drainage  through  a  fistula  often  causes  a 
marked  improvement. 

Indication  III.  Destroy  micro-organisms  or  clieclc  their  growth 
and  remove  pus  and  fermentation  products  from  the  hladder  by  means 
of  irrigation  of  the  bladder.  Washing  the  bladder  is  the  most  efficient 
mode  of  cleansing  the  bladder-walls  of  adherent  pus,  micro-organisms', 
and  urinary  salts.  The  micro-organisms  which  lie  beneath  the  mu- 
cous membrane  cannot  be  reached,  but,  by  lessening  the  congestion 
of  the  mucous  membrane  and  removing  decomposed  urine,  it  is  put 
in  a  condition  which  favors  its  recovery. 

Although  the  bladder  can  be  filled  by  hydrostatic  pressure  from 
an  irrigator,  it  requires  a  catheter  to  wash  it  out.  The  only  suitable 
forms  of  catheter  are  the  soft  rubber  and  the  gum  elastic.  They 
should  be  of  large  size  and  provided  with  two  eyes,  as  the  stream  flow- 
ing through  them  stirs  up  the  stagnant  urine  more  effectually  if  it 
enters  the  bladder  from  two  directions. 

A  large  hard-rubber  syringe  holding  five  ounces  may  be  used,  and 
has  the  advantage  that  it  is  possible  to  judge  of  the  extent  to  which 
the  bladder  is  filled  by  the  feeling  of  resistance,  to  the  inflowing 
stream,  offered  by  the  muscular  walls  of  the  bladder.    The  successive 


CYSTITIS. 


149 


Jets  entering  also  set  up  contractions  of  the  muscular  walls,  wliich 
have  an  influence  in  restoring  their  tone. 

The  general  custom  is  to  use  an  irrigator  raised  to  the  height  of 
two  to  four  feet  and  attached  t6  the  catheter  by  a  short  glass  connect- 
ing-tube. The  patient  should  rest  upon  a  table  or  sofa  in  a  half-sitting 
position,  and  the  anterior  urethra  should  be  irrigated  to  cleanse  it, 
before  the  catheter  is  carried  into  the  bladder. 

As  soon  as  a  sense  of  resistance  is  perceived  or  the  patient  feels 
pain,  the  inflow  should  be  stopped,  and  after  a  short  pause  the  fluid 
be  allowed  to  flow  out  again,  and  the  proceeding  repeated  until  the 
solution  comes  away  clear.  The  amount  of  fluid  necessary  to  flow  in 
at  one  time  is  small:  60  to  150  grammes  (from  2  to  5  ounces)  is 
enough. 

SOLUTIONS  FOR  WASHING  THE  BLADDER. 

For  simply  cleansing  the  walls  of  the  bladder  and  removing  ad- 
herent pus  and  decomposing  urine,  normal  salt  solution,  0.6  per  cent., 
or  boric-acid  water,  4  per  cent.,  in  strength,  are  well  adapted  to  the 
purpose.  Salicylic  acid,  3  parts  to  1000,  has  some  effect  in  checking 
the  fermentation  process. 

On  account  of  the  bacterial  origin  of  the  C3^stitis,  many  various 
antiseptics  have  been  recommended,  but  on  more  extended  trials  they 
have  proved  disappointing  and  have  fallen  into  disuse. 

Nitrate  of  silver  is  an  exception  to  the  antiseptics  just  mentioned, 
and  is  the  most  valuable  remedy  we  possess  in  suppurative  cystitis.  It 
should  be  used  in  the  strength  of  1-4000  up  to  1-1000  beginning  with 
the  weaker  and  gradually  increasing.  The  solution  should  be  retained 
in  the  bladder  two  or  three  minutes  and  then  allowed  to  flow  out  again. 
If  much  pain  is  caused  it  may  be  neutralized  by  washing  afterward 
with  salt  solution.  The  application  should  be  made  every  two  to 
three  days.  Permanganate  of  potash  is  less  useful  than  nitrate  of 
silver  in  cystitis,  but  is  occasionally  of  service. 

In  chronic  cystitis,  when  the  bladder  is  contracted  and  much  pain 
is  complained  of,  the  distension  attendant  upon  washing  the  bladder 
contra-indicates  its  use,  and  instillations  of  nitrate  of  silver  have  to  be 
substituted.  Twenty  drops  may  be  used  every  two  to  four  days,  from 
gr.  V  to  X  in  strength. 


250  DISEASES  OF  THE  BLADDER. 

SPECIFIC  CYSTITIS. 

GONORRHCEAL  CYSTITIS. 

Statistics  show  that  the  posterior  urethra  is. involved  in  80  per 
cent,  of  the  cases  of  gonorrhoea,  but  a  true  cystitis  arising  from  infec- 
tion of  the  bladder  mucous  membrane  with  gonococci  is  extremely 
rare,  although  a  few  cases  have  been  recorded. 

Inflammation  of  the  trigone  of  the  bladder  frequently  occurs  dur- 
ing the  course  of  a  gonorrhoea,  after  the  posterior  urethra  has  been 
attacked,  and  is  almost  always  due,  not  to  the  entrance  of  the  gono- 
cocci into  the  bladder,  but  of  some  other  pathogenic  organism,  and 
the  infection  is  therefore  of  the  mixed  variety. 

Its  symptoms,  course,  and  treatment  are  those  of  the  ordinary 
forms  of  suppurative  cystitis,  and  have  already  been  considered  under 
that  heading. 


TUBERCULOUS  CYSTITIS. 

Tubercular  involvement  of  the  bladder  occurs  most  frequently 
in  young  adults  between  the  ages  of  15  and  40,  although  no  age  is 
exempt. 

MODES  OF  INFECTION. 

Primary  infection  of  the  bladder  is  of  rare  occurrence,  although 
it  is  met  with  occasionally,  for,  so  long  as  the  vesical  epithelium  is 
intact,  it  affords  an  efficient  barrier  to  the  entrance  into  the  tissues 
of  any  tubercle  bacilli  which  may  have  foimd  their  way  into  the  blad- 
der. If  the  mucous  membrane  has  been  injured  or  eroded  by  the 
action  of  ammoniacal  urine,  the  tubercle  bacilli  can  easily  enter  the 
tissues.  For  this  reason  primary  tuberculosis  of  the  bladder  is  rare, 
and  when  the  bladder  becomes  tuberculous  it  is  usually  infected  from 
a  deposit  elsewhere. 

Secondary  infection  of  the  bladder  may  result  from  the  direct  ex- 
tension of  a  tuberculous  infiltration  of  the  seminal  vesicles  or  prostate 
or  the  bacilli  may  be  conve5^ed  by  the  lymphatics  or  blood-circulation 
from  the  kidneys  or  testicle.  Most  of  the  cases  of  bladder  tuberculosis, 
however,  originate  from  the  mural  transplantation  of  tubercle  bacilli 
contained  in  the  urine  from  a  tubercular  kidney. 


TUBERCULOUS  CYSTITIS.  151 

PATHOLOGICAL  CHANGES. 

The  tubercular  deposit  always  begins  around  the  vesico-urethral 
orifice  and  trigone  or  around  the  urethral  openings.  The  process 
does  not  last  long  as  a  pure  tuberculosis,  for  it  is  soon  complicated  by 
infection  with  other  micro-organisms,  causing  suppurative  cystitis  and 
ammoniacal  decomposition  of  urine. 

A  cystoscopic  examination  made  early  in  the  case  shows  a  few 
minute  papules  or  pin-head-sized  ulcerations,  and  later  in  the  disease 
are  to  be  seen  irregular-shaped  ulcerations  covered  with  a  deposit  of 
urinary  salts  and  sloughing  material,  and  the  base  of  the  ulcer  may  be 
covered  with  fungating  granulations,  which  bleed  easily. 

The  walls  of  the  bladder  in  some  places  become  hard  and  rigid 
and  in  others  are  softened,  and  its  capacity  is  diminished,  so  that  it 
may  only  hold  a  few  ounces  of  nrine.  The  cellular  tissue  surrounding 
the  base  of  the  bladder  becomes  the  seat  of  multiple  abscesses,  which 
break  and  form  fistulse. 

SYMPTOMS  AND  COURSE. 

Tuberculosis  of  the  bladder  begins  insidiously,  and  often  without 
any  apparent  cause.  Its  symptoms  are  those  of  cystitis,  viz.:  fre- 
quent urination,  pyuria,  and  hsematuria.  Bleeding  is  a  prominent 
symptom,  appears  early  in  the  disease,  and  is  more  or  less  persistent 
throughout  its  course. 

In  the  later  stages,  after  suppurative  cystitis  has  made  its  appear- 
ance, the  striking  symptom  is  the  painful  and  frequent  urination,  oc- 
casioned by  the  contraction  of  the  cavity  of  the  bladder  and  the  am- 
moniacal urine  coming  in  contact  with  its  ulcerated  walls.  The 
endeavor  to  rid  the  bladder  of  the  irritating  urine  causes  straining 
every  few  minutes,  which  is  accompanied  by  intense  pain.  The  kid- 
neys are,  after  a  time,  infected,  and  become  the  seat  of  abscesses.  Ab- 
scesses and  fistula  form  around  the  base  of  the  bladder,  and  the  patient 
dies  from  exhaustion  induced  by  the  incessant  pain  and  the  septic 
fever. 

DIAGNOSIS. 

Tuberculosis  should  always  be  suspected  when  a  young  man  of 
tubercular  heredity  develops  a  cystitis  without  any  apparent  exciting 
or  predisposing  cause,  which  runs  a  very  persistent  and  intractable 
course,  and  is  not  cured  by  the  ordinary  treatment. 

The  cystoscope  should  be  used  with  extreme  precautions  to  avoid 


152  DISEASES  OF  THE  BLADDER. 

causing  an  infection  of  the  bladder  with  piis-organisms.  It  may  show 
tubercles  in  groups  or  disseminated,  or  ragged,  punched-out,  irregular 
ulcers. 

A  microscopic  examination  of  the  pus  from  the  bladder  con- 
firms the  diagnosis  by  disclosing  tubercle  bacilli.  There  may  be  dif- 
ficulty in  finding  the  bacilli,  even  after  centrifugating,  as  they  are 
often  scanty.  If  none  are  found,  the  sediment  may  be  injected  into 
the  subcutaneous  tissues  over  the  abdomen  of  a  guinea-pig.  If  the 
animal  is  killed  four  weeks  later,  and  the  h'mph-glands  are  tuber- 
cular or  tubercular  nodules  are  disseminated  throughout  the  body,  the 
diagnosis  is  established. 

A  careful  search  should  always  be  made  for  tubercular  foci  in 
neighboring  organs,  and  nodules  may  usually  be  found  in  the  prostate, 
seminal  vesicles,  or  epididymis. 

Tubercular  involvement  of  the  kidney  often  exists  and  is  over- 
looked. The  symptoms  are  not  marked;  there  is  an  absence  of  renal 
pain  and  colic  and  no  tenderness  on  pressure.  It  may  be  suspected, 
however,  when  the  urine  is  persistently  of  a  low  specific  gravity  and 
acid  in  reaction,  and  when  the  pyuria  is  intermittent  in  character,  and 
the  amoimt  of  pus  is  greater  than  could  be  furnished  by  the  ulcers  in 
the  bladder. 

If  the  cystoscope  shows  a  tubercular  ulceration  about  Ihe  mouth 
of  one  ureter,  it  is  an  evidence  that  the  kidney  on  that  side  is  affected; 
but  the  point  can  only  be  definitely  determined  by  catheterizing  the 
ureters  or  making  use  of  Harrison's  rectal  segregator  and  examining 
separately  the  urine  from  each  kidney. 

PROGNOSIS. 

The  prognosis  in  tuberculosis  of  the  bladder  is  always  grave,  and 
recovery  is  exceedingly  rare,  but  the  disease  may  remain  latent  for 
years  unless  complicated  by  infection  with  pyogenic  micro-organisms. 
This  hastens  the  process;  the  kidne3's  are  liable  to  become  tubercular, 
and  the.  bladder  grows  rapidly  worse. 

TREATMENT. 

The  attempt  has  been  made  by  Guyon,  Eeverdin,  and  others  to 
cure  vesical  tuberculosis  in  its  earliest  stages  by  opening  the  bladder 
suprapubic  and  curetting  out  the  ulcers. 

The  resort  to  surgical  measures  in  the  besfinnins:  of  tuberculosis 


TUBERCULOUS  CYSTITIS.  5^53 

of  the  bladder,  in  the  hope  of  curing  the  disease,  is  to-day  practically 
abandoned.  The  bladder  infection  is  almost  always  secondary  to  tu- 
bercular deposits  in  other  organs  which  are  out  of  reach,  and  surgical 
interference  in  the  majority  of  cases  only  increases  the  rapidity  of  the 
course  of  the  disease. 

In  incipient  tuberculosis  of  the  bladder  the  indication  for  treat- 
ment consists  in  improving  the  vitality  of  the  tissues,  and  to  this  end 
life  in  the  open  air  or  a  long  sea-voyage  is  the  best  measure. 

Under  this  regime  patients  often  improve  and  a  few  recover. 
After  suppurative  cystitis  and  pyelitis  have  set  in,  no  benefit  is  to  be 
derived  from  leaving  home. 

Creasote  and. carbonate  of  guaiacol  are  recommended  by  some 
authorities,  and  by  others  are  considered  of  no  avail. 

Local  treatment  is  harmful,  as  a  rule.  The  tubercular  deposits 
cannot  be  reached,  and  there  is  danger,  in  bladder-washing  and  in- 
stillations, of  introducing  pus-organisms  and  causing  suppurative 
cystitis.  After  this  has  occurred,  the  instillation  of  corrosive  subli- 
mate (Guyon),  using  20  drops  of  1  to  5000  solution  and  increasing 
up  to  1  to  1000,  are  often  of  marked  benefit.  The  reaction  following 
is  rather  severe,  and  may  last  five  to  six  days,  and  should  be  allowed 
to  subside  before  repetition.  After  the  reactive  symptoms  have  passed 
away,  the  pain  of  urination  is  lessened  and  the  intervals  between  the 
acts  are  prolonged. 

Nitrate-of-silver  instillations  are  irritating,  and  aggravate  the  in- 
flammation. This  is  so  notably  the  case  that  a  violent  reaction  fol- 
lowing the  use  of  nitrate  of  silver  in  a  case  of  cystitis  suggests  that 
it  is  tubercular  in  origin. 

Later  in  the  disease,  when  the  pain  and  frequency  of  urination 
become  unbearable,  morphia  is  the  only  means  of  relieving  the  suffer- 
ing. 

As  time  goes  by  and  opium  fails  to  control  the  tenesmus  and 
frequent  micturition,  permanent  drainage  of  the  bladder  through  a 
fistula  should  be  established.  This  is  not  successful  in  relieving  the 
difficulty  entirely,  but  is  the  last  refuge  for  the  relief  of  the  intense 
suffering.  The  suprapubic  opening  is  to  be  preferred,  as  the  apparatus 
for  receiving  the  urine  can  be  more  easily  applied  and  the  patient  is 
not  long  confined  to  bed,  but  can  be  up  and  about. 

At  the  time  of  operation  the  bladder  may  be  inspected,  and  if  a 
few  isolated  tubercular  ulcers  are  found  they  can  be  removed  with 
the  curette  or  Paquelin  cautery  and  iodoform  rubbed  into  the  spots. 


]^54  DISEASES  OF  THE  BLADDER. 

The  subsequent  healing  of  the  ulcers  has  a  favorable  influence 
upon  the  pain  and  tenesmus,  and  the  permanent  fistula  in  the  bladder 
affords  an  opportunity  for  the  complete  and  painless  evacuation  of 
ammoniacal  urine  and  pus,  and  also  admits  of  its  cavity  being  kept 
clean  by  irrigations,  and  the  congested  mucous  membrane  can  also 
be  medicated  by  instillations  of  corrosive  sublimate  or  nitrate  of  silver. 

When  the  bladder  cavity  is  very  much  contracted  and  its  walls 
are  thick  and  rigid,  suprapubic  c3'stotomy  cannot  be  so  readily  per- 
formed, and  permanent  drainage  through  a  fistula  in  the  perineum 
has  to  be  resorted  to. 

There  is  always  the  danger,  in  establishing  an  artificial  fistula, 
that  the  wound  itself  may  be  infected  and  become  the  seat  of  a  tuber- 
cular infiltration,  increasing  the  extent  and  rapidity  of  the  progress 
of  the  disease.  The  perineal  wound  is  much  more  liable  to  infection 
than  the  suprapubic  opening,  and  should  only  be  used  when  the  supra- 
pubic fistula  is  impracticable. 


BACTERIURIA. 

This  condition  is  characterized  by  the  quantities  of  bacteria 
which  are  found  growing  in  the  urine,  which  is  entirely  free  from 
pus.  The  mucous  membrane  of  the  bladder  is  perfectly  healthy  and 
the  infection  is  confined  to  the  urine  alone. 

On  inspection  the  urine  appears  turbid  and  of  a  whitish-yellow 
color,  and  the  odor  is  very  disagreeable,  resembling  stale  fish  or  fascu- 
lent  material. 

On  centrifugating,  and  examining  the  sediment  microscopically, 
it  is  found  to  be  composed  of  the  bacillus  coli  communis  in  enormous 
quantities.    Pus  and  epithelial  cells  exist  in  very  small  numbers. 

It  is  often  impossible  to  trace  the  manner  in  which  the  bacteria 
gain  access  to  the  bladder,  although  in  most  of  the  cases  reported 
there  has  been  a  condition  of  hasmaturia,  enlargement  of  the  pros- 
tate requiring  catheterization,  stricture,  or  recent  gonorrhoea,  and  in 
women  a  recent  inflammation  of  the  pelvic  organs.  It  is  therefore 
supposed  that  the  bacteria  enter  the  bladder  (a)  through  the  urethra, 
(b)  with  the  urine  from  the  kidneys,  (c)  from  the  general  blood-cur- 
rent, or  (d)  from  adjacent  organs  through  the  lymphatics,  although 
their  place  of  proliferation  is  not  discoverable. 


BACTERIURIA.  t-- 

SYMPTOMS. 

The  symptoms  of  bacteriuria  are  not  marked,  and  the  turbid 
urine  with  a  foul  odor  is  often  the  only  sign. 

Sometimes  the  urination  is  frequent  and  urgent,  and  accompanied 
by  a  burning  pain  in  the  urethra,  and  rarely  a  chill  followed  by  fever, 
which  resembles  urinary  fever  in  its  onset  and  course,  is  noted. 


COURSE. 
The  course  of  the  disease  is  variable,  occasionally  brief  and  tran- 
sient, sometimes  more  protracted,  with  remissions  alternating  with 
exacerbations,  and  it  often  becomes  chronic,  lasting  for  years. 


PROGNOSIS. 

The  prognosis  is  rather  unfavorable  as  regards  a  cure,  unless  the 
place  of  bacterial  growth  is  accessible.  If  this  is  not  the  case,  the 
bacteria  are  apt  to  remain  permanently  in  the  urine,  but  the  general 
health  does  not  suffer  and  the  urinary  organs  remain  in  a  healthy 
state. 

DIAGNOSIS  AND  TREATMENT. 

The  diagnosis  can  only  be  made  by  excluding  cystitis  and  finding 
the  bacteria  in  the  urine  with  the  microscope. 

The  treatment  consists  in  first  removing  any  possible  source  of 
growth  for  the  bacteria  by  relieving  habitual  constipation  or  enteritis. 
If  the  breeding-place  of  the  micro-organisms  is  in  some  local  con- 
dition, such  as  a  posterior  urethritis  or  stricture,  it  should  be  removed. 

When  no  cause  is  discoverable,  the  administration  of  urinary  anti- 
septics internally, — salol,  methyl-blue,  and  Urotropin, — in  order  to 
destroy  the  bacteria,  is  called  for.  The  patient  should  drink  freely 
of  pure  distilled  or  spring-  water  in  order  to  mechanically  wasli  out 
and  remove  the  fermenting  contents  of  the  bladder. 

Bladder-washing  with  solution  of  nitrate  of  silver  or  sublimate 
is,  in  general,  of  little  use,  and  still  at  times  it  may  be  of  some  value. 


156 


DISEASES  OF  THE  BLADDER. 


TUMOKS  OF  THE  BLADDER. 

The  new  growths  which  occur  in  the  bladder  may  be  either 
benign  or  malignant.  The  benign  tumors,  or  papillomata,  appear  in 
different  forms:  (a)  As  villous  polypi,  composed  of  loops  of  blood- 
vessels, which  grow  and  project  into  the  cavity  of  the  bladder  in  long, 
waving  strings,  and  (h)  fibro-papillomata,  which  are  pedunculated 
tumors  of  a  firmer  consistence. 

Malignant  Tumors. 

Primary  cancer  of  the  bladder  is  exceedingly  rare,  but  secondary 
deposits  are  not  infrequent.     The  forms  in  which  it  presents  are  as 


Fig.  49. — Carcinoma  of  the  Bladder. 


sarcoma  or  carcinoma,  which  is  either  epithelial  or  the  glandular- 
celled  variety. 

They  are  less  apt  to  be  polypoid  in  appearance,  but  are  spread 
out,  infiltrating  the  tissues.  The  surface  is  covered  with  granulations 
or  villosities,  and  in  the  later  stages  is  ulcerated  and  presents  gaping 
ulcers.    The  tumors  are  often  multiple  and  their  development  is  slow. 


TUMORS  OF  THE  BLADDER.  I57 

Both  benign  and  malignant  forms  of  growth  are  usually  located 
in  the  region  of  the  trigone  or  near  the  openings  of  the  ureters. 

Tumors  of  the  bladder  predispose  to  cystitis,  which  in  time  leads 
to  disease  of  the  kidney,  either  suppurative  pyelitis  or  hydronephrosis, 
or  death  may  occur  from  the  constantly  recurring  hsemorrhages. 

If  cancer  of  the  bladder  is  primary,  it  is  not  apt  to  affect  distant 
organs. 

Vesical  calculus  is  a  frequent  complication  of  new  growths  in  the 
bladder  from  a  deposit  of  the  urinary  salts  upon  the  ulcerated  blad- 
der-wall or  upon  a  piece  of  necrotic  tissue  separated  by  sloughing. 


SYMPTOMS. 

Hsematuria  is  the  most  prominent  symptom  of  tumor  of  the  blad- 
der. It  comes  on  suddenly  and  without  provocation,  and  may  last  a 
few  hours  or  for  some  weeks.  The  quantity  of  blood  lost  is  variable 
and  fluctuating.  At  one  time  it  may  be  abundant  and  upon  the  next 
urination  the  water  may  be  almost  clear. 

Frequency  of  urination  and  tenesmus  are  often  present  in  the 
later  stages,  and  depend  upon  the  cystitis,  or  are  due  to  infiltration 
of  the  trigone  and  vesical  neck  by  a  malignant  growth.  Pain  is  never 
a  prominent  symptom,  and  when  it  occurs  it  is  occasioned  by  the 
cystitis. 

DIAGNOSIS. 

The  presence  of  a  tumor  due  to  malignant  disease  may  often  be 
felt  by  palpation,  placing  one  finger  in  the  rectum  and  making 
counter-pressure  over  the  pubes  with  the  other  hand. 

Any  thickening  of  the  trigone  can  be  appreciated  by  introducing 
a  sound  into  the  bladder  and  feeling  the  thickness  of  the  tissue  which 
lies  between  the  sound  and  the  finger  in  the  rectum. 

Polypoid  growths  are  not  capable  of  being  made  out  by  palpation. 

The  cystoscope  is  not  always  available,  on  account  of  the  amount 
and  rapidity  of  the  haemorrhage  obscuring  the  medium;  but  when  it 
is  possible  to  use  it  a  definite  diagnosis  of  the  conditions  can  be  made 
by  an  experienced  observer. 

Cystotomy,  either  perineal  or  suprapubic,  with  digital  exploration 
or  inspection  of  the  bladder,  affords  the  means  of  making  a  positive 
diagnosis. 

The  suprapubic  opening  is  to  be  preferred,  because  if  a  tumor 


258  DISEASES  OF  THE  BLADDER. 

is  present  it  can  be  removed  more  readily  than  through  a  perineal 
wound. 

PROGNOSIS. 

Benign  tumors,  if  let  alone,  may  cause  death  either  from  the 
repeated  haemorrhages  or  from  pyelonephritis  following  cystitis.  They 
can  be  readily  removed  by  operation,  but  are  apt  to  grow  again. 

Malignant  tumors  are  difficult  to  remove  completely,  as  they  in- 
filtrate the  bladder-wall  and  are  liable  to  recur.  Authorities  give  the 
duration  of  life  at  from  two  to  three  years  after  the  commencement 
of  the  disease. 

TREATMENT. 

The  hsemorrhage  is  sometimes  controlled  by  hot  injections  of 
alum,  5iv  to  the  pint;  fluid  extract  of  hydrastis,  5ij  to  the  pint;  or 
acetanilid,  5ij  to  the  pint. 

Clots  retained  in  the  bladder,  if  moderate  in  size,  may  be  let 
alone,  as  they  will  soften  and  be  passed  naturally. 

If  the  bladder  should  become  greatly  distended  by  retention  of 
urine,  the  clots  may  be  withdrawn  by  a  large  catheter  and  suction 
syringe  or  a  litholapaxy  evacuating  tube  and  aspirator. 

If  the  bleeding  continues  and  is  persistent,  suprapubic  cystotomy 
should  be  performed  without  further  delay.  The  suprapubic  opening 
affords  an  opportunity  for  inspecting  the  interior  of  the  bladder,  and 
through  it  the  tumor  may  be  removed. 

Polypoid  growths  are  best  treated  by  cutting  through  the  mucous 
membrane  at  their  bases,  removing  the  whole  tumor,  and  sewing  up 
the  incision  with  catgut  sutures,  or  they  may  be  removed  by  crushing 
or  twisting  off  with  forceps  or  by  the  sharp  spoon,  or  they  may  be 
burned  off  Avith  the  Paquelin  cautery  or  the  galvano-caustic  loop. 

Infiltrating  growths,  which  are  always  malignant,  cannot  be  re- 
moved by  these  means,  but  require  the  complete  extirpation  of  the 
portion  of  the  bladder-wall  upon  which  they  are  located. 

If  the  tumor  should  be  found  too  extensive  for  removal,  the 
suprapubic  opening  should  be  maintained  as  a  means  of  permanently 
draining  the  bladder  of  decomposing  urine  and  blood-clots. 


CHAPTER   XIL 

VESICAL  CALCULUS. 

The  stones  which  form  in  the  bladder  are  classified,  according  to 
their  composition,  into  three  varieties: — 

(a)  Uratic  calculi,  which  are  made  up  of  uric  acid  and  urates. 
They  form  about  three-fifths  of  the  total  number  of  calculi,  and  are 
the  softest  of  any  in  their  consistence. 

(b)  Oxalic  calculi  are  composed  of  oxalate  of  lime.  They  occur 
less  frequently  than  the  others,  the  estimated  proportion  being  about 
3  per  cent.  They  are  the  hardest  and  heaviest  of  all  the  varieties,  and 
are  usually  studded  with  numerous  projecting  nodules,  from  which 
they  derive  the  name  of  mulberry  calculi. 

(c)  Phosphatic  calculi  are  formed  from  phosphates  and  carbon- 
ates, which  are  often  combined  with  urate  of  ammonia.  Phosphatic 
stones  are  not  so  hard  as  the  oxalic,  but  harder  than  the  uratic  stones. 
They  are  never  due  to  constitutional  or  diathetic  conditions,  but  are 
always  the  result  of  cystitis  and  decomposing  urine,  from  which  the 
salts  are  deposited  and  agglutinated  together  by  the  pus. 

Stones  composed  of  a  single  element  alone  are  rarely  met  with. 
As  a  rule,  two  or  more  elements  are  found  together,  arranged  in  con- 
centric layers  around  the  nucleus. 

The  formation  of  a  calculus  is  not  a  simple  process  of  a  deposit 
of  salts,  and  it  is  a  common  occurrence  for  urine  to  contain  crystals 
of  uric  acid,  oxalates,  or  phosphates  for  a  long  time  without  the  for- 
mation of  a  stone;  but  in  the  presence  of  albuminoid  material  these 
crystals  change  their  molecular  form,  and  gain  a  tendency  to  coalesce 
and  adhere  to  each  other  and  also  to  a  sort  of  frame-work  composed 
of  colloid  material,  which  is  furnished  by  the  pus. 

The  practical  deduction  to  be  drawn  from  this  fact  is  that,  while 
crystals  may  be  present  in  the  urine  for  years  without  the  formation 
of  a  stone,  a  cystitis  producing  pus  gives  the  necessary  stimulus  to 
coalescence,  and  a  stone  is  very  liable  to  form. 

NUMBER. 

Stones  are  usually  single,  although  very  frequently  they  are  mul- 
tiple; sometimes  five  or  six  may  be  present,  and  instances  are  on  record 
where  three  or  four  hundred  stones  were  taken  from  the  bladder. 

(159) 


100  DISEASES  OF  THE  BLADDER. 

It  occasionally  happens  that  a  single  stone  becomes  multiple 
through  a  process  of  spontaneous  fracture. 

It  has  been  found  in  laboratory  experiments  that,  if  a  calculus 
formed  in  a  solution  of  gum  were  placed  in  a  solution  of  a  different 
specific  gravity,  it  would  split  up  into  segments.  Hence  it  is  probable 
that  the  instances  reported  of  the  spontaneous  fracture  of  stones  in 
the  bladder,  which  have  been  accredited  to  different  mineral  or  spring- 
waters,  is  due  to  the  effect  produced  upon  the  stone  by  surrounding 
it  with  urine  whose  specific  gravity  and  reaction  have  been  changed 
from  their  original  state  at  the  time  of  formation  of  the  stone  by  the 
ingestion  of  large  quantities  of  water.  The  albuminoid  material  form- 
ing the  frame-work  of  the  stone  absorbs  fluid  and  swells,  bursting 
apart  the  laminae  of  the  stone  and  so  fracturing  it  into  segments. 


ETIOLOGY. 

For  a  calculus  to  form,  it  is  absolutely  essential  that  there 
should  be  a  foreign  body  in  the  bladder,  since  the  crystals  must  have 
a  nuchus  around  which  they  may  coalesce  and  adhere. 

The  nucleus  may  be  a  foreign  body  introduced  from  without, 
such  ?s  i^  broken  catheter-  or  pipe-  stem,  pin,  etc.,  or  it  may  be  a 
small  piece  of  necrotic  tissue  which  has  been  sloughed  off  from  the 
bladder-wall. 

In  many  cases  of  stone,  however,  the  nucleus  is  composed  of 
uratic  crystals.  These  become  agglomerated  in  the  kidney  and  pass 
through  the  ureter,  causing  renal  colic.  They  drop  into  the  bladder, 
and,  if  they  are  not  voided  through  the  urethra,  form  a  nucleus. 

Predisposing  Causes  of  Uratic  and  Oxalic  Calculi.  —  As  these 
stones  are  dependent  upon  a  constitutional  or  diathetic  state,  certain 
things  which  influence  the  general  condition  of  bodily  health  play 
an  important  role  in  their  formation. 

It  has  been  generally  supposed  that  the  habitual  drinking  of 
water  impregnated  with  the  salts  of  lime  was  very  apt  to  occasion 
vesical  calculus.  Investigations  to  determine  this  point  show  that 
the  cases  of  calculus  are  not  equally  distributed  through  the  lime- 
stone districts,  and  that  they  are  just  as  common  in  the  adjacent 
regions  where  the  water  is  free  from  lime,  and  on  these  accounts  the 
limestone  theory  has  been  abandoned. 

Diet  and  constitutional  habit,  however,  are  important  factors  in 
the  production  of  stone,  since  the  excretion  of  uric  and  oxalic  acids 


Fig.  50. — Oxalic  or  Mulberry  Calculus.     (Author's  Specimen,  from 
Kings  County  Hospital.) 


Fig.  51.— Vesical  Calculus,  split  in  two  Halves,  showing  mode  of 
formation,  by  a  deposit  of  Phosphates  in  Concentric  Layers,  around  a 
Uric-Acid  Nucleus.  Weight,  1370  Grains.  (Author's  Specimen,  from 
Kings  County  Hospital.) 

(161) 


Fig.  52. — Multiple  Phosphatic  Calculi,  removed  by  Suprapubic 
Cystotomy  from  same  Patient.  (Author's  Specimen,  from  Kings 
County  Hospital.) 


Fig.  53.— Calculi  which  formed  in  the  Bladder  as  a  Single  Stone, 
which  underwent  Spontaneous  Fracture.  Afterward  fragments  passed 
into  the  Prostatic  Urethra,  where  they  became  impacted,  and  were 
removed  by  External  Urethrotomy.  (Author's  Specimen,  from  Kings 
County  Hospital.) 

(163) 


VESICAL  CALCULUS. 


165 


depends  upon  the  quality  of  the  food  and  the  diathesis.  On  this 
account  children  with  feeble  digestive  powers,  who  eat  largely  of 
nitrogenous  food,  are  unable  to  perform  the  processes  of  oxidation 
completely,  and  the  results  of  the  retrograde  metamorphosis  of  the 
tissues  are  eliminated,  not  as  urea,  which  is  freely  soluble,  but  as 
urates  or  oxalates. 

The  same  is  also  true  of  adults,  who  eat  more  nitrogenous  food 
than  they  require,  use  alcohol  and  malt  liquors  freely,  and  take  but 
little  exercise.  Such  persons  are  subject  to  attacks  of  gout  or  various 
manifestations  of  lithsemia,  which  are  included  under  the  term  of 
gouty  diathesis. 

The  gouty  diathesis  is  notably  an  inherited  condition,  and  on 
that  account  different  members  of  successive  generations  of  a  family 
are  liable  to  develop  oxalic  or  uratic  stone  in  the  bladder  or  some 
other  gouty  manifestation. 

Phosphatic  stones  are  not  constitutional  in  their  origin,  but  are 
dependent  upon  purely  local  causes.  They  result  in  consequence  of 
urine  decomposing  and  throwing  down  crystals  of  the  triple  phos- 
phates, which  are  glued  together  by  muco-pus,  and  form  nuclei, 
around  which  crystallization  goes  on  rapidly. 

On  this  account  any  obstruction  which  prevents  the  bladder 
from  emptying  itself — such  as  stricture,  hypertrophied  prostate,  and 
paralysis — allows  residual  urine  to  accumulate,  and,  if  cystitis  occurs, 
alkaline  fermentation  of  the  urine,  deposit  of  crystals,  and  stone- 
formation  result. 

SYMPTOMS. 

While  it  is  possible  for  a  small  stone  to  exist  for  years  without 
producing  marked  symptoms,  and  particularly  so  if  it  lie  in  the 
pouch  behind  an  enlarged  prostate,  it  is  usual  for  a  stone  in  the 
bladder  to  give  rise  to  the  following  prominent  symptoms:  (a)  pain, 
(6)  increased  frequency  of  urination,  (c)  blood,  and  (d)  sudden  stop- 
page of  urine  in  full  stream. 

The  pain  is  referred  to  the  head  of  the  penis  under  the  glans, 
and  shoots  into  the  perineum  and  down  the  thighs. 

It  is  felt  especially  at  the  end  of  urination,  for,  as  the  last  few 
drops  of  urine  are  expelled,  the  muscular  contractions  of  the  bladder 
drive  the  stone  forcibly  into  its  neck,  causing  a  contusion. 

The  pain  is  increased  by  riding  in  a  jolting  wagon,  by  going 
downstairs,  or  even  by  walking. 


IQQ  DISEASES  OF  THE  BLADDER. 

Increased  frequency  of  urination  occurs  through  the  day,  when 
the  patient  is  about  on  his  feet  and  the  stone  is  moving  in  the 
bladder.  At  night,  when  the  individual  is  quiet  in  bed,  the  stone  does 
not  move,  and  the  intervals  between  urination  are  longer. 

Blood  never  appears  in  any  large  quantity  in  the  urine,  but  a 
few  drops  are  squeezed  out  at  the  end  of  urination,  or  it  may  be 
mixed  with  urine,  giving  it  a  smoky  color.  It  is  not  a  constant 
symptom,  but  intermittent. 

Sudden  stoppage  of  the  urine  in  full  stream  is  a  very  character- 
istic symptom,  when  it  is  present,  and  is  caused  by  the  stone  being 
carried  into  the  vesical  outlet,  obstructing  it  and  shutting  off  the 
flow  of  urine  like  a  valve. 

It  is  rarely  observed  in  old  men  with  enlarged  prostates,  as  the 
stone  lies  in  the  deep  posterior  prostatic  pouch. 

Cystitis  always  exists  when  a  stone  is  present,  and  the  symptoms 
of  calculus  are  complicated  by  those  of  inflammation  of  the  bladder. 

DIAGNOSIS. 

The  clinical  history  of  stone  is  merely  suggestive  of  the  condi- 
tion, but  to  make  a  positive  diagnosis  the  stone  must  be  touched 
with  an  instrument  or  through  an  incision  in  the  bladder  or  seen 
with  the  cystoscope. 

Examination  with  Thompson's  Searcher,  or  Sounding  for  Stone. 
— The  patient  should  lie  on  his  back,  and  with  old  men  it  is  desirable 


^lt.iLU.LU.It^LA..^I-- 


A 


Fig.  54. — Thompson's  Searcher  for  Vesical  Calculus. 

to  elevate  the  hips  so  that  the  stone  may  roll  out  of  the  post- 
prostatic  pouch.  The  bladder  should  contain  from  four  to  six  ounces 
of  sterilized  water,  in  order  to  distend  its  folds  and  allow  the  beak 
of  the  searcher  to  move  freely. 

The  searcher  is  introduced  after  the  manner  of  a  sound,  and 
the  trigone  and  post-prostatic  pouch  should  be  examined  by  turning 
the  beak  of  the  searcher  from  side  to  side  and  rotating  it  behind 
the  prostate,  as  the  stone  always  lies  in  the  most  dependent  portion 
of  the  bladder. 

If  the  stone  is  not  touched,  the  fluid  in  the  bladder  should  be 


VESICAL  CALCULUS. 


1G7 


allowed  to  flow  out  through  the  hollow  shaft  of  the  searcher,  and, 
as  the  bladder  collapses,  the  stone  is  often  brought  up  against  the 
point  of  the  searcher  and  the  impact  can  be  felt. 

There  are  certain  precautions  to  be  observed  in  sounding  for 
stone.  The  patient's  genitals  should  be  cleansed  and  the  instruments 
must,  of  course,  be  sterile.  Children  should  always  be  examined 
under  chloroform,  as  otherwise  they  would  be  restless,  and  the  bladder 
might  be  wounded  by  a  sudden  movement. 

In  old  men  there  is  a  great  deal  of  danger  of  urinary  fever. 
They  should  be  examined  at  home  and  kept  in  bed  from  twenty-four 


Fig.  55. — Searching  for  Stone  Lying  in  the  Post-prostatic  Pouch. 


to  forty-eight  hours  after  the  examination.  It  is  always  desirable  to 
administer  salol  or  Urotropin  for  two  days  before  searching. 

If  there  is  a  strong  suspicion  of  the  presence  of  a  stone,  it  is  ad- 
visable to  make  all  the  preparations  for  immediate  operation,  in 
order  to  avoid  the  reaction  which  so  often  follows  an  examination 
of  the  bladder. 

The  presence  of  a  stone  is  perceived  by  the  searcher  and  gives 
rise  to  a  sharp  click,  which  can  be  felt  and  heard.  Soft  stones  give 
a  dull  or  muffled  sound  when  touched,  but  the  sound  is  sharper  in 
character  when  a  hard  stone  is  struck. 

The  size  of  a  stone  may  be  measured  by  grasping  it  between  the 
jaws  of  a  lithotrite;  but  the  determination  of  the  size  or  number  of 


IQg  DISEASES  OF  THE  BLADDER. 

the  stones  is  difficult  with  the  searcher,  and  for  this  purpose  the 
cystoscope  is  of  great  value. 

With  this  instrument  it  is  possible  to  see  the  stones  distinctly, 
unless  the  bladder  is  bleeding  freely,  and  their  size,  shape,  and  loca- 
tion can  all  be  accurately  ascertained. 

Phosphatic  stones  are  white  and  round,  uratic  stones  are  yellow- 
ish and  oval,  and  oxalic  concretions  are  dark  and  covered  with  bosses 
and  sharp  points;  but  it  should  be  remembered  that  most  stones 
are  composed  of  different  elements  arranged  in  concentric  layers.  At 
the  same  time  the  position  of  the  stone  may  be  ascertained,  for  a 
stone  lying  in  a  deep  pouch  behind  an  enlarged  prostate  or  attached 
to  the  bladder-wall  as  an  incrustation  or  lying  in  a  saccular  dilata- 
tion will  often  be  out  of  reach  of  a  searcher,  and  may  be  overlooked. 

An  examination  of  the  urine  often  throws  light  on  the  character 
of  the  stone  by  revealing  the  predominant  form  of  the  urinary 
crystals. 


Fig.  56. — Nitze's  Observation  Cystoscope. 

The  litholapaxy  pump  is  sometimes  useful  in  detecting  a  small 
stone  which  eludes  the  searcher.  The  tube  is  introduced  and  water 
forced  into  the  bladder  with  the  bulb.  The  outflow  of  the  water 
forces  the  stone  against  the  orifice  of  the  tube,  and  the  click  is 
appreciable  to  the  ear  and  to  the  touch. 

Since  the  introduction  into  practice  of  the  cystoscope  the 
exploration  of  the  bladder  through  a  suprapubic  or  perineal  wound 
is  rarely  called  for. 

In  former  times  it  was  often  necessary  in  doubtful  cases,  particu- 
larly in  the  instance  of  a  calculus  lying  in  a  saccular  dilatation  or  in 
the  presence  of  an  incrustation  of  the  bladder-wall  with  urinary 
crystals. 

PREVENTIVE  TREATMENT. 
The  presence  of  crystals  in  freshly-voided  urine  which  is  still 
warm  should  be  regarded  as  an  indication  that  calculus  is  liable  to 
form,  and  the  tendency  to  the  formation  of  uratic  and  oxalic  stones 


VESICAL  CALCULUS. 


169 


should  be  guarded  against  by  attention  to  the  patient's  general 
health.  He  should  be  cautioned  against  using  an  excess  of  nitrog- 
enous food,  sugar,  or  fat.  It  is  in  general  thought  best  not  to  cut 
off  all  the  nitrogenous  food,  but  to  allow  a  general  diet,  with  a  reduc- 
tion of  the  accustomed  quantity  of  meat. 

Moderate  and  systematic  daily  exercise  in  the  open  air  is  of 
great  assistance  in  favoring  oxidation. 

The  ingestion  of  large  quantities  of  pure  spring-  or  distilled 
water  has  the  effect  of  diluting  concentrated  urine,  rendering  soluble 
its  contained  salts,  and  flushing  out  the  kidneys. 

If  the  urine  is  strongly  acid,  citrate  of  potash  is  indicated  in 
order  to  render  it  neutral. 

If  phosphates  are  abundant  and  due  to  imperfect  assimilation, 
the  mineral  acids,  particularly  phosphoric,  in  doses  of  mxv  three 
times  a  day,  and  the  vegetable  bitters  improve  the  digestive  powers. 
The  phosphaturia  often  disappears  for  a  time  and  sometimes  perma- 
nently under  the  use  of  TJrotropin,  gr.  viij  three  times  a  day,  or 
benzoic  acid. 

The  adoption  of  local  measures  for  preventing  the  formation  of 
phosphatic  calculi  is  much  oftener  crowned  with  success. 

As  these  stones  are  always  caused  by  the  decomposition  of  alka- 
line urine  in  the  presence  of  cystitis,  the  indications  are  (a)  to  drain 
the  bladder  by  removing  a  stricture,  if  present,  and  evacuating 
residual  urine,  in  cases  of  enlarged  prostate  or  atony  and  distension 
of  the  bladder  in  paralytics,  and  (b)  to  cure  the  existing  cystitis  by 
bladder-washing. 

In  this  way  the  decomposition  of  urine  is  checked  and  the  pre- 
cipitation of  phosphates  and  carbonates  ceases. 

Attempts  to  dissolve  stones  after  their  formation  have  been 
made  for  many  years,  but,  while  some  have  been  moderately  success- 
ful in  the  laboratory,  no  method  has  yet  been  found  which  is  capable 
of  dissolving  a  stone  in  the  bladder. 

The  various  waters  from  mineral  springs  which  have  derived 
some  reputation  as  solvents  owe  it  to  the  fact,  already  spoken  of, 
that  in  a  few  extremely  rare  instances  spontaneous  fracture  of  the 
stone  occurs  when  the  specific  gravity  of  the  fluid  surrounding  it  is 
altered. 


170  DISEASES  OF  THE  BLADDER. 

OPERATIVE  TREATMENT. 

Litholapaxy,  or  crushing  the  stone  and  immediately  washing 
out  the  fragments  from  the  bladder,  is  the  operation  of  choice  in 
all  cases  of  vesical  calculus. 

It  is  a  prerequisite  of  the  operation  that:  I.  The  lithotrite  and 
evacuating  catheters  should  be  introduced  easily  and  without  wound- 
ing the  urethra  or  prostate.  In  children  under  sixteen  years  of  age 
litholapaxy  is  regarded  by  many  surgeons  as  inadmissible  on  account 
of  the  small  size  of  the  bladder  and  urethra. 

It  is  advised,  however,  by  others  whenever  the  urethra  is  large 
enough  to  admit  the  instruments. 

II.  The  stone  must  be  movable  in  the  bladder,  of  moderate  size, 
and  not  too  hard. 

If  a  stone  lies  in  a  saccular  dilatation  or  is  adherent  to  the 
bladder-wall,  it  cannot  be  crushed.  Very  large  stones  form  such  a 
great  quantity  of  debris  after  crushing  that  the  operation  of  washing 
out  becomes  too  protracted. 

The  contra-indications  to  litholapaxy  are  (a)  extreme  prostatic 
hypertrophy.  The  prostate  may  be  so  much  enlarged  that  the  litho- 
trite cannot  be  introduced,  or,  even  if  passed  into  the  bladder,  it 
cannot  reach  and  grasp  the  stone  as  it  lies  in  the  post-prostatic  pouch. 

(b)  Tight  stricture  of  the  deep  urethra.  Such  a  narrowing  of  the 
urethra  will  prevent  the  passage  of  the  instruments,  and  requires  ex- 
ternal urethrotomy  for  its  cure,  and,  at  the  same  time,  the  stone  may 
be  removed  through  the  perineal  wound,  although  if  very  large  it  may 
have  to  be  crushed  with  a  lithotrite  first. 

(c)  Severe  cystitis  which  does  not  yield  to  ordinary  treatment. 
In  this  condition  it  is  better  to  remove  the  stone  through  an  incision, 
which  will  subsequently  serve  for  the  prolonged  drainage  of  the 
bladder  and  at  the  same  time  afford  an  opportunity  for  its  irrigation. 

(d)  Contracted  and  irritable  bladder  does  not  admit  of  sufficient 
distension,  and  is  too  intolerant  of  instruments  to  allow  the  stone 
to  be  crushed. 

(e)  Nephritis  and  suppurative  pyelitis,  since  urgemic  coma  and 
death  follow  litholapaxy,  when  the  kidneys  are  diseased,  more  fre- 
quently than  after  the  cutting  operations. 

Technique. — The  patient,  with  his  rectum  previously  emptied, 
is  anaesthetized,  lying  upon  his  back.  The  hips  are  elevated,  to  allow 
the  stone  to  roll  out  of  the  post-prostatic  pouch. 


VESICAL  CALCULUS. 


171 


The  bladder  is  washed  out  and  filled  with  six  to  eight  ounces  of 
boric-acid  solution. 

The  lithotrite  is  passed  through  the  urethra  after  the  manner 
of  a  sound,  and  rests  on  the  floor  of  the  bladder  behind  the  prostate, 


Fig.  57. — Bigelow's  Lithotrite. 


Fig.  5S. — Method  of  Grasping  the  Stone  in  Lithotrity. 


with  its  beak  pointing  upward.  The  lithotrite,  from  its  weight,  sinks 
in  and  forms  a  depression  in  the  wall  of  the  bladder.  Ordinarily 
the  stone  lies  alongside  the  beak  of  the  lithotrite,  and  when  the  jaws 
are  opened  it  rolls  in  between  them.     The  jaws  are  closed  and  the 


172 


DISEASES  OF  THE  BLADDER. 


stone  is  felt  to  be  grasped.  If  the  jaws  fail  to  seize  the  stone,  the 
blades  are  opened  in  the  upright  position,  turned  over  on  one  side, 
and  shut  along  the  floor  of  the  bladder.  If  the  stone  is  not  found,  the 
manoeuvre  is  repeated  in  the  opposite  direction. 

If  the  stone  lies  in  a  deep  post-prostatic  pouch,  raising  the  pa- 
tient's hips  may  roll  it  out  within  reach,  or  it  may  be  pried  up  by  a 
finger  in  the  rectum. 

In  the  event  of  these  failing,  the  jaws  of  the  lithotrite  may  be 
turned  so  as  to  point  downward,  in  the  hope  of  seizing  the  stone  as 


Fig.  59. — Bigelow's  Evacuator. 


it  lies;  but  in  this  case  there  is  always  danger  of  nipping  and  cutting 
out  a  piece  of  the  bladder-wall. 

When  the  stone  has  been  caught  between  the  jaws,  the  resistance 
it  offers  is  easily  felt  on  approximating  them.  The  blades  of  the 
lithotrite  are  then  locked,  and  by  turning  the  handle  the  jaws  are 
screwed  together,  comminuting  the  stone  into  fragments.  The 
manoeuvres  of  opening  the  jaws,  catching  the  stone,  and  breaking  it 
are  repeated  till  the  surgeon  perceives  that  no  large  fragments  are 
left,  and  the  lithotrite  is  withdrawn. 

The  next  step  is  the  evacuation  of  the  debris.     The  evacuating 


VESICAL  CALCULUS. 


173 


tube  is  introduced  into  the  bladder  and  its  contained  fluid  allowed  to 
flow  out  with  a  gush,  carrying  with  it  some  of  the  fragments.  The 
bladder  is  then  filled  with  water  by  pumping  in  the  contents  of  the 
bulb,  and  the  fluid  then  flow's  out  again  into  the  receiver,  carrying 
more  fragments.  The  pumping  is  continued  till  no  more  fragments 
come  away,  and  auscultation  over  the  bladder  fails  to  perceive  the 
click  of  a  fragment  remaining  behind  which  is  too  large  to  enter 
the  tube.  If  this  is  the  case  the  lithotrite  should  be  introduced  again 
and  the  piece  crushed  and  pumped  out. 

The  after-treatment  consists  in  keeping  the  patient  in  bed  and 
allowing  him  to  drink  freely  of  water,  to  keep  the  kidneys  active. 

If  retention  of  urine  occurs,  it  is  well  to  tie  a  catheter  in,  in 
order  to  avoid  the  irritation  of  its  frequent  passage. 

After  ten  days  have  passed  the  bladder  should  be  pumped  once 
more  to  remove  the  sand  and  mucus  which  is  left  and  which  might 
serve- as  a  nucleus  for  another  stone,  and  the  entire  absence  of  frag- 
ments should  be  verifled  by  a  cystoscopic  examination. 

Mortality  of  Litliolapaxy. — The  following  statistics,  compiled  by 
Cabot,  show  the  death-rate  at  different  times  of  life: — 

Children  under  14,  241  cases,  with     4  deaths  =  1.66  per  cent. 
Adults,  14  to  50,      400       "         "      13        "      =3.25     "       " 
Old  men,  433       "         "      26        "      =6  "       " 

Perineal  Lithotomy. — Until  within  a  few  years,  and  before  the 
technique  of  litholapaxy  and  suprapubic  lithotomy  was  perfected,  the 
only  way  of  removing  a  stone  was  through  a  perineal  incision. 

At  the  present  time  the  perineal  operation  has  fallen  into  almost 
entire  disuse,  except  in  children.  It  offers  the  advantage  of  good 
drainage  for  the  bladder,  but  its  disadvantages  are  hsemorrhage, 
which  is  difficult  to  control,  and  the  bruising  and  laceration  of  the 
tissues  caused  by  dragging  the  stone  through  a  small  incision,  which 
leads  to  infection  and  sloughing.  For  these  reasons  the  mortality 
is  higher  with  stones  over  1  V*  inches  in  diameter  after  the  perineal 
operation  than  following  suprapubic  lithotomy. 

Perineal  lithotomy  is  particularly  dangerous  in  old  men  with 
enlarged  prostates,  and  should  not  be  undertaken  without  some 
urgent  reason. 

It  is  also  difficult  to  reach  a  stone  from  the  perineum  when  the 
prostate  is  very  much  enlarged,  on  account  of  the  increased  length  of 
the  perineal  distance.    Before  the  fifty-fifth  year  a  small  stone  can 


174 


DISEASES  OF  THE  BLADDER. 


be  removed  with  greater  safety  through  a  median  perineal  incision 
than  by  suprapubic  lithotomy,  but  ordinarily  such  cases  are  better 
treated  by  litholapaxy. 

The  indications  for  median  perineal  lithotomy  may  be  tabulated 
as  follows: — 

(a)  Small  stones  of  not  more  than  1  ^/^  inches  in  diameter, 
complicated  by  stricture  of  the  urethra,  which  demands  external 
urethrotomy. 

(&)  Small  stones  in  the  presence  of  atony  of  the  bladder  with 


Fig.  60. — Lithotomy-staff. 


no  expulsive  power,  and  chronic  cystitis,  provided  that  the  prostate 
is  not  very  much  enlarged. 

(c)  Contracted  and  irritable  bladder,  which  does  not  admit  of 
sufficient  distension  for  suprapubic  cystotomy  and  is  too  intolerant 
to  allow  litholapaxy. 

Perineal  Lithotrity. — Eeginald  Harrison  has  enlarged  the  scope 


Fig.  6L — Lithotomy-knife. 


of  median  lithotomy  by  devising  a  lithotrite  which  is  introduced 
through  a  median  incision  and  by  which  stones  of  considerable  size 
can  be  crushed  in  the  bladder  and  removed  through  the  perineal 
wound. 

Perineal  Litliotormj. — Technique. — (a)  Median  Operation. — This 
is  simply  a  loutonniere,  or  external  urethrotomy,  and  is  performed  by 
introducing  a  grooved  lithotomy-staff  through  the  urethra  into  the 
bladder. 

The  staff  is  held  steadily  by  an  assistant  and  the  surgeon  makesJ 


VESICAL  CALCULUS. 


175 


a  direct  thrust  or  stab  with  a  long,  straight  bistoury,  an  inch  and  a 
half  in  front  of  the  rectum,  through  the  tissues  lying  in  front  of 
the  urethra,  and  strikes  the  groove  in  the  staff.  A  gorget  is  then 
slid  along  the  groove  until  it  enters  the  bladder,  which  is  explored 


Fig.  62. — Lithotomy-forceps. 


Fig.  63.— Blizard's  Probe-Pointed  Knife. 

by  means  of  the  finger.    If  a  stone  is  found  it  is  grasped  by  the  stone 
forceps  and  withdrawn,  if  not  too  large. 

If  the  stone  prove  too  large  to  pass  through  the  wound,  (&) 


Fig.  64. — Incision  Through  the  Urethra  and  Prostate 
in  Lateral  Lithotomy. 

perineal  lithotrity  may  be  performed  by  introducing  Harrison's  litho- 
trite,  crushing  the  stone,  and  either  extracting  or  pumping  out  the 
fragments  with  a  litholapaxy  evacuator. 

The   operation   may,   if   desired,   be   converted   into    (c)    lateral 


176  DISEASES  OF  THE  BLADDER. 

perineal  lithotomy,  which  was  the  operation  formerly  used  exclusively 
in  all  cases  of  stone.  A  Blizard  knife  is  slid  along  the  groove  in 
the  staff,  as  it  rests  in  the  bladder,  until  the  point  of  the  knife  has 
entered  the  bladder.  The  knife  is  then  withdrawn,  making  a  sweep- 
ing cut,  outward,  downward,  and  a  little  to  the  left,  enlarging  the 
original  median  incision  and  cutting  through  the  left  lobe  of  the 
prostate,  the  perineal  muscles,  and  the  skin. 


Fig.  65. — Lithotomy-scoop. 

In  this  way  the  incision  is  made  of  sufficient  size  to  permit  the 
extraction  of  large  stones  with  the  forceps  or  scoop;  but,  on  ac- 
count of  the  drawbacks  of  haemorrhage  and  laceration  of  the  tissues, 
this  form  of  lithotomy  is  rarely  used  at  the  present  time. 

After-treatment  of  Perineal  Lithotomy.  —  The  wound  is  never 
sewed,  but  is  left  to  heal  by  granulation.  Haemorrhage  is  inconsider- 
able after  the  median  operation,  and  is  easily  controlled  by  a  gauze 
packing  around  a  large  soft-rubber  catheter.  It  is  often  very  severe 
after  a  lateral  lithotomy,  and  often  requires  the  use  of  the  shirted 
cannula  to  hold  it  in  check. 

The  mortality  of  perineal  lithotomy  has  been  tabulated  by  Freyer 
and  Rosenthal,  as  follows: — 

Deaths  before  the  20th  year 5  to     8  per  cent. 

"       in  adults 10    "   15     "       " 

"       above  the  40th  year 33    "   39     "       " 

These  figures  refer,  in  the  main,  to  the  operation  of  lateral 
lithotomy,  and  apply  less  to  median  lithotomy  or  lithotrity. 

Suprapubic  Lithotomy.  —  Suprapubic  lithotomy  was  first  per- 
formed in  the  year  1550  by  Pierre  Franco,  but  did  not  gain  favor 
until  1880,  when  the  application  of  aseptic  methods  and  improve- 
ments in  the  technique  of  the  operation  reduced  the  previously  high 
rate  of  mortality. 

At  the  present  time,  in  the  cases  where  litholapaxy  cannot  be 
applied  and  a  cutting  operation  must  be  employed,  suprapubic  lithot- 
omy is,  under  most  conditions,  the  operation  of  choice. 


VESICAL  CALCULUS.  ^i^^ 

The  advantages  of  suprapubic  over  perineal  lithotomy  are: — 

(a)  The  suprapubic  operation  admits  of  complete  inspection  and 
evacuation  of  the  bladder. 

(b)  Wounding  the  ejaculatory  ducts,  neck  of  the  bladder,  and 
rectum,  and  dangerous  haemorrhage  from  incised  blood-vessels  are 
avoided.  ' 

(c)  The  laceration  and  bruising  of  the  tissues,  which  occurs 
when  a  large  stone  is  dragged  through  a  perineal  wound,  are  avoided. 

(d)  The  bladder  is  rendered  easy  of  access,  while  in  the  presence 
of  a  considerable  degree  of  prostatic  hypertrophy  the  perineal  dis- 
tance is  so  much  increased  that  it  may  be  impossible  to  reach  the 
bladder  from  below. 

The  special  indications  for  suprapubic  lithotomy  have  been  tabu- 
lated as  follows: — 

(a)  Very  large  stones,  even  though  they  be  soft,  (h)  Large, 
hard  stones,  (c)  All  fixed  stones,  incrustations  of  the  bladder-wall, 
sacculated  stones,  etc.  (d)  Cases  where  a  high  degree  of  prostatic 
hypertrophy  exists  which  prevents  the  seizure  of  the  stone  by  the 
lithotrite. 

The  technique  of  the  operation  is  based  upon  the  anatomical 
fact  that,  when  the  bladder  is  filled,  the  fold  of  peritoneum,  which 
lies  in  front  of  it,  is  raised  up  two  inches  above  the  pubes,  leaving 
a  space,  called  the  space  of  Retzius  or  prevesical  space,  uncovered  hy 
peritoneum,  through  which  the  bladder-wall  may  be  safely  incised. 

Technique. — The  India-rubber  bag  which  was  used  in  the  earlier 
operations  for  distending  the  rectum,  and  so  bringing  the  bladder 
nearer  to  the  abdominal  wall,  is  rarely,  if  ever,  employed  at  present. 
The  Trendelenburg  posture  is  only  exceptionally  required. 

A  catheter  is  introduced  through  the  urethra  and  the  bladder  is 
filled  with  from  eight  to  twelve  ounces  of  sterilized  water  by  means 
of  a  syringe.    Helferich  and  Bristow  use  air  for  this  purpose. 

The  catheter  is  withdrawn  and  a  rubber  band  is  tied  around 
the  root  of  the  penis. 

An  incision  is  made  in  the  median  line  of  the  abdomen,  be- 
ginning three  inches  above  the  pubes  and  extending  down  over  it, 
which  divides  the  skin  and  subcutaneous  fat.  There  is  no  linea  alba 
in  this  region  and  the  incision  is  carried  directly  through  the  mus- 
cular bundles,  and  the  transversalis  fascia  is  divided.  The  edges  of 
the  wound  are  held  apart  by  large  angular  retractors  and  the  bladder 
appears  lying  at  the  bottom  of  the  wound.     It  is  recognized  by  its 


178 


DISEASES  OF  THE  BLADDER. 


shape  and  by  the  prevesical  fat,  which  is  adherent  to  it.  If  any  doubt 
exists,  it  may  be  punctured  with  an  exploring  hypodermic  syringe. 

In  old  men  the  peritoneal  fold  in  front  of  the  bladder  is  some- 
times unusually  long,  and  extends  down  low  into  the  space  of  Retzius. 
In  such  a  case  it  should  be  peeled  up  from  the  bladder  and  held  out 
of  the  way.  If  the  peritoneum  is  accidentally  wounded,  it  should 
be  at  once  sewed  up  with  fine  catgut. 

After  the  bladder  is  exposed,  it  should  be  steadied  with  a  sharp 
hook,  thrust  through  its  wall  at  the  upper  angle  of  the  wound,  and 
two  long  silk  retraction  sutures  are  passed  through  the  bladder-walls, 
at  the  sides  of  the  wound. 

These  are  held  by  an  assistant  and  the  bladder  is  opened  between 
them  by  means  of  a  stab-like  thrust,  with  a  long,  sharp  bistoury. 
As  the  water  in  the  bladder  is  flowing  out,  the  incision  may  be  en- 
larged to  the  desired  extent  by  means  of  a  straight,  blunt-pointed 
bistoury. 

The  cavity  of  the  bladder  is  then  searched  with  the  finger,  and 
the  stone  removed  with  a  lithotomy-scoop  or  forceps.  If  it  is  desired 
to  inspect  the  interior  of  the  bladder,  its  walls  may  be  distended  by 
Watson's  bladder  speculum  and  the  cavity  illuminated  by  Pilcher's 
electric  lamp  or  a  head-mirror  and  reflected  light. 

The  advisability  of  sewing  the  wound  in  the  bladder  or  of  leav- 
ing it  open  is  still  under  discussion.  All  authorities,  however,  agree 
that  in  the  presence  of  severe  suppurative  cystitis  and  foul  purulent 
urine,  the  bladder  should  not  be  sewed,  but  left  open  for  drainage. 
With  a  moderately-healthy  bladder  in  young  persons,  opinions  differ, 
and  the  following  plans  are  adopted: — 

(a)  Kocher  sutures  the  wound  in  the  bladder  with  a  double  row 
of  sutures,  the  flrst  row  including  the  mucous  membrane,  and  the 
second  row,  which  may  be  a  continuous  suture,  includes  the  muscular 
and  serous  coats  of  the  bladder.  The  space  of  Retzius  is  packed  with 
gauze,  and  the  wound  in  the  abdomen  left  open  for  several  days.  If 
the  stitches  in  the  bladder  hold,  the  abdominal  wound  may  be  closed 
by  secondary  suture.  Drainage  of  the  bladder  is  provided  for  by 
a  permanent  catheter  introduced  either  through  the  urethra  or 
preferably  through  a  small  perineal  incision. 

(b)  In  addition  to  suturing  the  wound  in  the  bladder  the  abdom- 
inal incision  is  also  closed  by  sutures,  excepting  the  lower  angle, 
through  which  a  wisp  of  gauze  is  inserted  for  drainage. 


VESICAL  CALCULUS. 


179 


(c)  The  wounds  in  the  bladder  and  abdominal  wall  are  not  su 
tiired,  but  are  left  open  and  allowed  to  heal  by  granulation. 

By  this  latter  method  the  convalescence  is  prolonged  and  the 
patient  is  subjected  to  a  great  deal  of  inconvenience  from  the  urine 
flowing  out  over  the  wound  and  wetting  the  bed  continually.  To 
avoid  this  objection,  the  following  plans  for  drainage  have  been  sug- 
gested:— 

(a)  Guyon's  double  tubes.  Two  large  rubber  drainage-tubes  are 
introduced  through  the  abdominal  wound  into  the  base  of  the  blad- 
der, and  gauze  packed  around  them. 

(b)  In  addition  to  the  suprapubic  tubes,  permanent  catheteriza- 
tion through  a  houtonniere  is  carried  out. 

(c)  The  Dawbarn  bladder-drain  consists  in  a  reservoir  of  water 
hung  upon  the  wall  and  from  which  the  water  flows  out  through  a 
rubber  tube.  This  rubber  tube  is  connected  to  a  single  tube  intro- 
duced into  the  bladder  by  a  T-shaped  glass  tube.  As  the  water  flows 
out  of  the  reservoir  a  suction  is  created  which  keeps  the  bladder  empty. 

(d)  The  Bloodgood  bladder-drain  which  is  a  rubber  bag  attached 
to  a  hard-rubber  tube  entering  the  bladder.  The  urine  flows  out 
through  it  and  is  collected  and  retained  in  the  rubber  bag. 

The  length  of  time  required  for  the  healing  of  the  wound  is 
from  two  to  three  weeks  when  the  bladder  is  sutured,  and  from  three 
to  six  weeks  when  the  wound  is  left  to  heal  by  granulation. 

The  after-treatment  may  be  attended  with  difficulties,  and  there 
is  always  danger  of  urinary  infiltration  of  the  walls  of  the  wound. 
In  order  to  avoid  this  it  has  been  recommended,  and  particularly  so 
in  the  presence  of  a  foul  cystitis,  to  open  the  abdomen  first,  and  to 
make  the  incision  into  the  bladder  several  days  later. 

In  the  time  elapsing  between  the  two  operations  granulations 
have  had  time  to  form  and  septic  absorption  is  prevented. 

The  mortality  statistics  of  suprapubic  lithotomy  collected  by 
Cabot  show  the  following  results: — 


Age. 

Cases. 

Deaths. 

Percentage. 

Adults,   14  to   50  years.. 

100 

12 

12 

Old  men   

53 

17 

32 

180 


DISEASES  OF  THE  BLADDER. 


OPERATIONS  FOR  CALCULUS  IN  CHILDREN. 

Perineal  Lithotomy. — The  median  operation  is  impracticable  in 
children,  on  account  of  the  difficulty  in  withdrawing  a  stone  through 
the  small  posterior  urethra.  For  the  same  reason  Harrison's  litho- 
trite  cannot  be  used.  The  lateral  operation,  however,  can  be  readily 
performed  with  much  greater  safety  than  in  adults,  for,  as  the  pros- 
tate and  urethra  grow  larger,  they  become  more  vascular,  and  the 
danger  of  hagmorrhage  increases. 

The  lateral  operation  has  a  drawback  in  the  danger  of  wounding 
the  ejaculatory  seminal  duct  and  producing  sterility  on  that  side,  in 
after-life.  The  mortality  is  about  3  per  cent.,  and  lateral  lithotomy 
is  still  generally  considered  to  be  the  operation  of  choice  in  the  case 
of  small  stones  in  children. 

Litholapaxy  in  children  is  attended  with  some  difficulties,  on 
account  of  the  small  size  of  the  urethra  interfering  with  the  intro- 
duction of  the  lithotrite  and  the  relative  hardness  of  the  stones,  as 
met  with.  In  spite  of  this  it  has  been  performed  a  great  many  times, 
and  the  death-rate  is  low:  only  about  3  per  cent.  As  far  as  the 
death-rate  is  concerned,  there  is  but  little  choice  between  lateral 
lithotomy  and  litholapaxy. 

Suprapubic  cystotomy  in  children  is  more  dangerous,  according 
to  the  collected  statistics,  than  either  of  the  other  operations,  the 
mortality  being  about  10  per  cent.,  although  stones  one  and  one- 
quarter  inches  in  diameter  or  over  are  considered  too  large  for  lateral 
lithotomy  and  must  be  removed  through  a  suprapubic  incision. 

The  size  of  a  stone  is  readily  estimated  in  children  by  the  bi- 
manual examination  with  one  finger  in  the  rectum  and  the  other 
hand  over  the  bladder. 


DISEASES  OF  THE  PROSTATE. 


CHAPTER   XIIL 

SENILE  HYPERTROPHY  OF  THE  PROSTATE. 

The  prostate  is  placed  like  a  sphincter  around  the  first  inch  of 
the  urethra.  It  consists  of  two  lateral  lobes  and  a  median  central 
portion  connecting  them,  which  is  sometimes  spoken  of  as  the  third, 
or  median,  lobe.  In  its  histological  structure  it  resembles  the  uterus 
in  the  female,  and  is  composed  of  muscular  fibres,  glandular  ele- 
ments, and  a  connective-tissue  stroma  uniting  them. 

While  the  gland  may  be  enlarged  as  a  result  of  gonorrhoea  or 
sexual  abuses  in  young  men,  true  hypertrophy  of  the  prostate  never 
occurs  until  the  decline  of  life,  when  other  degenerative  changes  in- 
cident to  advancing  years  begin.  It  is  almost  never  observed  until 
the  patient  is  past  his  fiftieth  year. 

Sir  Henry  Thompson  states  that  hypertrophy  of  the  prostate 
exists  in  34  per  cent,  of  men  at  and  above  60  years  of  age,  and  that 
it  produces  manifest  symptoms  in  about  15  or  16  per  cent,  of  the 
cases,  when  it  is  enlarged. 

The  cause  of  hypertrophy  of  the  prostate  is  entirely  unknown. 

PATHOLOGY. 

The  pathological  change  consists  in  a  general  enlargement  of 
the  entire  organ,  or  the  increase  in  size  may  be  confined  to  one  or 
both  lateral  lobes  or  to  the  median  lobe.  The  character  of  the  en- 
largement of  the  gland  and  its  size  and  consistency  depend  upon 
which  of  the  normal  tissues  of  the  prostate  have  been  chiefly  affected 
by  the  process  of  hypertrophy. 

The  first  change  which  occurs  is  a  growth  of  the  gland-tubules 
with  their  associated  muscle,  so  as  to  form  a  new  gland-substance 
closely  resembling  the  normal  prostatic  substance.  This  constitutes 
the  first  or  glandular  stage  of  hypertrophy. 

In  this  stage  small  tumors  often  form  in  the  substance  of  the 

(181) 


182  DISEASES  OF  THE  PROSTATE. 

prostate,  causing  an  enlargement,  which  is  irregular  and  which  may 
impinge  upon  the  urethra  and  cause  it  to  become  distorted. 

After  a  varying  length  of  time  degenerative  changes  set  in, 
which  ultimately  convert  the  new  tissue  into  a  mass  of  more  or  less 
dense  fibrous  connective  tissue,  containing  the  atrophied  remains  of 
the  glandular  and  muscular  elements.  This  constitutes  the  second 
or  fibrous  stage. 

After  the  adenomatous  structures  have  been  obliterated  by  the 
degenerative  changes,  the  enlargement  of  the  prostate  becomes  even 
and  symmetrical,  and  instead  of  being  soft  and  elastic,  as  in  the 
glandular  stage,  it  is  very  hard  and  dense. 

The  hypertrophy  may  consist  in  an  overgrowth  of  both  glandu- 
lar and  stromal  tissues  in  equal  proportions,  causing  a  symmetrical 
enlargement  of  the  prostate,  which  is  not  excessive  and  seldom  causes 
any  symptoms. 

The  size  to  which  the  prostate  may  grow  depends  upon  the 
nature  of  the  tissue  involved.  The  prostate  may  be  only  slightly 
increased  in  size  or  it  may  become  as  large  as  a  hen's  egg  or  an 
orange,  and  in  very  exceptional  instances  may  reach  the  size  of  a 
cocoa-nut,  and  fill  up  the  entire  pelvis. 

Form  of  Obstruction. — In  certain  cases  the  lateral  lobes  may  be 
enlarged,  but  in  such  a  way  as  not  to  interfere  with  the  urinary  out- 
let, and  it  is  possible  to  empty  the  bladder  entirely.  As  a  rule,  how- 
ever, the  posterior  median  portion,  or  third  lobe,  becomes  enlarged, 
and  assumes  the  shape  of  a  bar  or  dam  across  the  mouth  of  the  blad- 
der, behind  which  the  urine  accumulates  and  cannot  flow  out,  or  the 
outgrowth  may  be  more  circumscribed  in  form  and  act  as  a  ball-valve, 
which  shuts  down  over  the  vesical  orifice. 

Alexander  has  recently  suggested  that  the  enlarged  prostate  in- 
terferes with  the  rhythmical  contraction  of  the  detrusor  muscle,  in 
the  region  of  the  trigone,  and  the  bladder,  on  this  account,  is  in- 
capable of  emptying  itself  of  the  last  few  ounces  of  urine,  which  are 
normally  expelled  by  the  action  of  this  muscle.  This  view  will  serve 
to  account  for  the  cases  in  which  there  is  no  appreciable  obstruction 
in  the  shape  of  a  projecting  outgrowth  from  the  prostate,  but  where 
residual  urine  accumulates. 

In  many  instances  the  enlargement  oif  the  prostate  does  not  pro- 
duce any  symptoms,  and  it  is  only  of  consequence  when  it  acts  as  an 
obstruction  placed  at  the  outlet  of  the  bladder,  thus  preventing  it 
from  completely  evacuating  its  contained  urine. 


Fig.  66. — Prostatic  Hypertrophy.  Median  Enlargement,  in  the 
form  of  a  Bar.  Suitable  for  Bottini's  Operation.  A  large  Bladder. 
(By  Courtesy  of  Dr.  F.  S.  Watson.) 


(183) 


■  ■'  -'.  ,r^****''' «, 


Fig.  67. — Prostatic  Hypertrophy.  Enlargement  of  Lateral  Lobes 
and  Median  Portion.  Bladder  Contracted  and  Non-distensible.  (By 
Courtesy  of  Dr.  F.  S.  Watson.) 


(185) 


Fig.  68. — Prostatic  Hypertrophy.  Enlargement  of  Lateral  and 
Median  Lobes.  Deep  Post-prustatic  Pouch.  (By  Courtesy  of  Dr.  F.  S. 
Watson.) 


(187) 


SENILE  HYPERTROPHY  OF  THE  PROSTATE. 


189 


The  various  symptoms  and  diseased  conditions  which  occur  in 
consequence  of  the  prostatic  hypertrophy  are  all  due  to  two  condi- 
tions:— 

(a)  The  obstruction  caused  by  the  enlargement  of  the  prostate 
at  the  vesical  outlet  interferes  with  the  urinary  outflow,  and  the 
bladder  cannot  be  completely  emptied  by  the  muscular  efforts  of  the 
patient.  Eesidual  urine  accumulates,  pathological  changes  occur  in 
the  bladder-wall,  and  secondarily  the  ureters  and  kidneys  become 
afCected. 


Fig.  69. — Prostatic  Hypertrophy.  Enlargement  of  the  Lateral 
Lobes,  with  Increase  in  Size  of  the  Median  Portion,  Forming  a  Bar, 
Through  Which  a  False  Passage  has  been  Made. 

(b)  The  return-flow  of  venous  blood  from  the  bladder-wall  is 
prevented  by  the  pressure  exerted  upon  the  veins  by  the  enlarged 
prostate,  and  a  congestion  of  the  bladder-walls  occurs  as  a  result. 

Changes  in  the  Urethra. — In  consequence  of  the  enlargement 
of  the  prostate,  notable  alterations  occur  in  the  prostatic  urethra: — 

(a)  It  becomes  elongated. 

(b)  The  normal  curve  is  changed. 

(c)  The  calibre  of  the  urethra,  instead  of  being  round,  is  flat- 
tened from  side  to  side  by  the  pressure  of  the  lateral  lobes,  so  that 
it  becomes  a  vertical  slit. 


190 


DISEASES  OF  THE  PROSTATE. 


As  a  result  of  these  changes  catheters  of  ordinary  shape  are 
often  inapplicable  to  cases  of  prostatic  hypertrophy,  and  special 
catheters  have  to  be  employed. 

SYMPTOMS. 
One  of  the  first  symptoms  of  enlarged  prostate  which  a  patient 
observes  is: — 

I.  Difficulty  in  starting  the  flow  of  urine. 
In  addition  to  this  is  noted: — 

II.  Deficiency  in  the  force  of  the  stream. 


Fig.  70. — Prostatic  Hypertrophy-     Pedunculated  Middle  Lobe 
Obstructing  Passage  of  a  Catheter. 


Both  of  these  symptoms  are  occasioned,  in  part,  by  the  feeble 
and  atonic  condition  of  the  muscular  fibres  of  the  bladder,  and  partly 
on  account  of  the  prostatic  obstruction. 

III.  Frequent  calls  to  urinate  especially  at  night. 

This  symptom  is  explained  by  the  fact  that  the  enlarged  prostate 
presses  on  the  plexus  of  veins  lying  around  it,  and  so  obstructs  the 
flow  of  venous  blood.  As  the  blood  from  the  bladder  is  returned 
through  this  plexus,  any  interference  with  its  circulation  causes  a 
passive  congestion  of  the  bladder-walls.  Through  the  day  the  mus- 
cular activity  improves  the  circulation,  but  at  night  the  muscles  are 
in  repose,  and  a  passive  hypergemia  occurs. 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  191 

The  increased  frequency  of  urination  at  night  often  helps  to  dis- 
tinguish a  case  of  enlarged  prostate  from  one  of  vesical  calculus.  In 
the  case  of  a  stone  the  desire  to  urinate  is  more  frequent  during  the 
day,  when  the  stone  is  rolling  about  in  the  bladder,  but  at  night  the 
patient  is  quiet  in  bed,  and  the  stone  does  not  cause  much  irritation. 

One  of  the  most  important  conditions  from  the  stand-point  of 
treatment  and  prognosis,  which  enlarged  prostate  gives  rise  to,  is 
residual  urine.  Eesidual  urine  may  be  defined  as  the  urine  which 
remains  in  the  bladder  after  the  patient  has  voluntarily  tried  to  evac- 
uate it  completely,  and  always  occurs  as  a  result  of  an  obstruction. 

Residual  urine  exists  in  the  majority  of  cases  of  prostatic  hyper- 
trophy, and  in  the  early  stages  and  in  cases  of  slight  obstruction  may 
only  amount  to  an  ounce  or  two.  The  tendency  is  for  it  to  increase  in 
quantity  as  the  bladder-walls  become  atonic  and  the  prostatic  en- 
largement becomes  more  developed;  so  that  in  exceptional  cases  it 
may  reach  a  quart  in  quantity. 

After  residual  urine  has  existed  for  a  varying  length  of  time 
cystitis  is  generally  excited  by  the  entrance  into  the  bladder  of  micro- 
organisms, coming  from  the  urethra  or  rectum  or  introduced  arti- 
ficially upon  a  dirty  catheter. 

The  causation  of  cystitis  is  favored  by  the  stagnant  residual 
urine  and  also  by  the  catarrhal  mucus,  which  is  formed  in  the  con- 
gested mucous  membrane  lining  the  bladder  as  a  result  of  its  condi- 
tion of  chronic  passive  hyperemia. 

The  urea  of  the  urine  is  decomposed  by  bacterial  action,  as- 
sisted by  the  presence  of  the  catarrhal  mucus,  and  carbonate  of 
ammonia  is  set  free.  The  urine  becomes  alkaline  in  reaction  and 
ammoniacal  in  odor,  is  strongly  irritating,  and  adds  still  further  to 
the  existing  inflammation  of  the  bladder-wall. 

When  cystitis  is  well  established,  the  frequency  of  urination  is 
increased,  and  the  patient  urinates  as  frequently  hy  day  as  at  night. 

The  mucous  membrane  of  the  bladder  surrounding  the  urethral 
orifice  becomes  turgid  and  congested,  and  serves  to  occlude  still  more 
the  outlet  from  the  bladder,  and  the  residual  urine  increases.  The 
various  changes  dependent  upon  cystitis  and  obstruction  lead  to 
changes  in  the  wall  of  the  bladder.  In  order  to  furnish  sufficient 
propelling  force  to  overcome  the  obstruction  formed  by  the  prostatic 
overgrowth,  the  muscular  fibres  of  the  bladder-wall  undergo  hyper- 
trophy. The  bundles  of  muscular  fibres  grow  larger  and  project  into 
the  bladder,  and  diminish  its  capacity. 


192 


DISEASES  OF  THE  PROSTATE. 


The  muscular  efforts  of  the  bladder  force  the  urine  between  the 
bundles  of  muscle,  and  in  time  saccular  dilatations  form,  which  may 
be  as  large  as  the  bladder  itself.  As  these  sacs  are  only  covered  out- 
side with  peritoneum  and  the  serous  w^all  of  the  bladder  and  have 
no  muscular  fibres,  they  cannot  empty  theinselves.  In  consequence, 
the  urine  stagnates  and  decomposes,  and  it  frequently  happens  that 
a  calculus  forms  in  them. 

In  course  of  time  as  the  case  progresses  the  hypertrophy  gives 
place  to  atrophy  and  distension.  The  distension  of  the  thinned 
bladder-wall  may  be  very  great;  so  much  so,  that  it  may  contain  a 
quart  of  residual  urine  and  reach  as  high  as  the  umbilicus. 

The  distension  occurs  so  gradually  that  the  patient  is  unaware 
of  his  condition,  and  notices  only  a  slight  feeling  of  weight  in  the 
abdomen,  and  that  his  habitually  frequent  urination  is  slightly  in- 
creased. As  the  residual  urine  increases,  the  bladder  grows  more  dis- 
tended and  the  intervals  between  the  acts  of  urination  become  still 
shorter.  After  the  bladder  is  stretched  and  distended  to  its  utmost 
capacity  a  new  symptom  occurs:  that  of  incontinence  of  urine,  or 
constant  dribbling. 

The  bladder  is  so  full  that  it  can  hold  no  more,  and  the  over- 
taxed sphincter  yields,  allowing  the  escape  of  a  small  quantity  of 
urine  every  few  minutes. 

The  conditions  of  decomposing  residual  urine  and  cystitis  just 
described  provide  suitable  conditions  for  the  formation  of  phosphatic 
calculi.  As  Keyes  expresses  it,  "Stone  is  the  logical  sequence  of 
obstruction  to  urinary  outflow  aided  by  vesical  catarrh." 

The  stagnant  decomposing  urine  deposits  salts,  which  become 
glued  together  by  muco-pus  into  a  solid  concretion,  or  are  deposited 
upon  a  nucleus,  which  may  be  a  bit  of  necrotic  tissue  sloughed  off 
from  the  bladder-w^all. 

A  single  stone  or  several  may  exist  without  causing  any  symp- 
toms, and  they  may  lie  unsuspected  for  months  in  the  pocket  behind 
an  enlarged  middle  lobe.  Their  surfaces  are  smooth,  and  they  are 
prevented  from  rolling  about  in  the  bladder,  and  the  weakened  mus- 
cular fibres  of  the  bladder  cannot  drive  them  forcibly  out  of  the 
post-prostatic  pouch  against  the  vesical  orifice  during  the  act  of 
urination. 

It  sometimes  happens  that  after  hypertrophy  begins  the  bladder- 
wall,  instead  of  growing  weakened  and  atonic  and  ultimately  becom- 
ing dilated,  undergoes  hypertrophy  with  contraction.    In  this  condi- 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  I93 

tion  the  overgrowth  of  the  prostate  does  not  form  an  obstruction  to 
the  outflow  of  urine,  and  residual  urine  does  not  accumulate,  and  the 
bladder,  instead  of  being  distended  and  enlarged,  undergoes  a 
diminution  in  the  size  of  its  cavity,  so  that  it  may  only  contain  six 
or  eight  ounces  of  urine  when  fully  distended. 

In  addition  to  the  contraction  of  its  size  there  is  also  a  perma- 
nent congestion  of  the  vesical  neck  from  pressure  on  the  veins  by  the 
enlarged  prostate.  This  venous  engorgement  occasions  an  extreme 
irritability  of  the  bladder,  with  an  almost  constant  desire  to  urinate. 

Of  the  two  conditions  spoken  of,  the  patient  with  an  atonied, 
relaxed  bladder  which  does  not  cause  him  trouble,  even  though  it  is 
incapable  of  emptying  itself  except  by  catheter,  suffers  far  less  in- 
convenience than  the  man  who  has  an  hypertrophied  irritable  blad- 
der, and  is  tormented  continually  with  an  intolerable  desire  to 
urinate. 

Changes  in  Kidneys  and  Ureters. — As  the  obstruction  offered 
by  the  prostate  increases,  a  greater  amount  of  muscular  effort  is 
required  to  empty  the  bladder,  and,  as  a  result  of  the  pressure,  the 
urine  is  forced  back  into,  the  ureters,  causing  them  to  become  dis- 
tended, and  sac-like  dilatations  form  at  various  points. 

The  backward  pressure  and  damming  back  of  the  urine  is  con- 
tinued, and  saccular  dilatations  of  the  pelves  of  the  kidneys  occur, 
giving  rise  to  hydronephrosis. 

The  salts  of  the  stagnant  decomposing  urine  are  deposited,  and 
calculi  are  apt  to  form  in  the  various  dilatations  in  the  kidney. 

The  process  of  dilatation  becomes  further  complicated  by  germ- 
infection,  which  usually  ascends  up  the  ureters,  and  as  a  result  causes 
pyelitis  or  abscess  of  the  kidney. 

Retention  of  urine  occurs  in  nearly  every  case  of  enlarged  pros- 
tate, and  presents  itself  in  two  forms: — 

(a)  Acute  Retention.— This  occurs  suddenly  in  an  individual 
who  up  to  that  time  had  been  able  to  pass  water  with  a  fair  degree 
of  freedom.  It  is  frequently  brought  on  by  chilling  or  wetting  the 
surface  of  the  body  and  taking  cold.  The  sudden  congestion  of  the 
mucous  membrane  around  the  vesical  orifice  causes  it  to  swell  up 
and  occlude  the  opening  entirely,  in  the  same  way  that  a  cold  in  the 
head  will  close  up  the  nasal  passages. 

On  the  other  hand,  the  retention  may  be  occasioned  by  a  spas- 
modic contraction  of  the  cut-off  muscle  (spasmodic  stricture),  which 
occurs  as  a  reflex  from  constipation  and  scybala  in  the  rectum,  or  an 


^g_j^  DISEASES  OF  THE  PROSTATE. 

acid  condition  of  the  urine  from  overindulgence  in  wine  or  malt 
liquors. 

(b)  Chronic  retention,  as  already  described,  is  caused  by  the  ob- 
struction at  the  vesical  outlet  from  the  enlarged  prostate  and  partly 
induced  by  the  atonic  condition  of  the  muscular  walls  of  the  bladder. 

DIAGNOSIS. 

In  the  case  of  a  man  over  fifty  years  of  age,  complaining  of  diffi- 
culties of  urination,  enlarged  prostate  should  always  be  suspected. 

It  is  desirable  to  conduct  the  examination  systematically,  and 
to  that  end 

I.  A  rectal  examination  should  be  made,  to  feel  the  prostate  and 
judge  of  its  size  and  consistency  and  to  determine,  if  possible, 
whether  the  enlargement  is  fibrous  or  glandular  in  character. 

Of  course,  only  the  posterior  portion  of  the  gland  can  be  felt 
through  the  rectum,  and  it  is  impossible  to  determine  the  shape  of 
the  obstructing  overgrowth  in  this  way,  but  its  density  and  the 
extent  of  the  enlargement  of  the  entire  gland  can  be  determined  by 
the  rectal  touch. 

II.  The  quantity  of  residual  urine  should  be  collected  and  meas- 
ured after  the  following  method:  The  patient  is  requested  to  pass 
water,  and  endeavors  to  empty  the  bladder  completely.  A  catheter 
is  then  introduced  into  the  bladder,  and  all  the  urine  which  remains 
behind  and  which  the  patient  was  unable  to  void  spontaneously  is 
known  under  the  term  "residual  urine."  The  residual  urine  should 
be  measured  and  set  aside  for  microscopic  examination. 

The  quantity  of  residual  urine  indicates  the  extent  to  which  the 
prostatic  enlargement  interferes  with  the  complete  emptying  of  the 
bladder;  but  in  order  to  determine  the  shape  of  the  outgrowth  which 
projects  up  into  the  bladder  and  blocks  its  outlet,  we  must  have  re- 
course to  the  cystoscope. 

At  the  time  of  collecting  the  residual  urine  we  can  also  deter- 
mine the  length  of  the  urethra  by  measuring  the  distance  from  the 
eye  of  the  catheter  to  the  point  upon  its  shaft  to  which  it  is  necessary 
to  introduce  it  before  the  urine  begins  to  flow.  This  measurement 
often  fails  to  demonstrate  an  existing  enlargement,  as  a  decided 
amoimt  of  obstruction  may  be  present  which  causes  but  very  little 
elongation  of  the  urethra. 

III.  By  means  of  a  cystoscopic  examination  it  is  possible  to  see 
the  enlargement  of  the  middle  lobe  projecting  upward,  and  to  some 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  ;^95 

extent  to  see  a  lateral  lobe  if  it  impinges  upon  the  vesical  outlet.  As 
the  cystoscope  is  introduced  through  the  urethra  it  will  also  serve 
to  exclude  the  presence  of  a  tight  stricture,  and  by  its  use  in  the 
bladder  we  can  prove  the  presence  or  absence  of  vesical  calculus, 
which  is  so  apt  to  be  present  in  cases  of  enlarged  prostate  with 
residual  urine. 

There  are  certain  precautions  to  observe  in  every  examination 
of  prostatic  cases:  The  patients  are  old  men  whose  vitality  is  low  and 
who  are  more  or  less  feeble.  Their  urinary  passages  are  in  an  irri- 
table condition,  and  they  are  very  liable  to  urinary  fever,  and  any 
prolonged  or  rough  examination  is  apt  to  be  followed  by  chills,  fever, 
and  constitutional  disturbances.  For  these  reasons  the  instruments 
should  be  aseptic,  and  when  practicable  it  is  desirable  to  cleanse  the 
urethra  and  bladder  by  irrigation  before  instrumentation. 

The  instruments  should  be  used  with  extreme  gentleness  to  avoid 
any  traumatism,  which  would  allow  the  entrance  of  micro-organisms 
into  the  circulation,  and  the  first  examination  should  not  be  too  pro- 
longed. 

It  is  desirable  that  the  patient  should  be  examined  for  the  first 
time  in  his  own  home,  so  that  he  can  go  to  bed  at  once  after  the 
examination,  and  thus  avoid  the  necessity  of  going  out-of-doors, 
running  the  risk  of  chilling  the  body. 

A  distended  bladder  should  never  be  emptied  at  the  first  sitting. 
Cases  are  on  record  where  sudden  death  has  occurred  when  a  full 
bladder  has  been  emptied  by  the  catheter  with  the  patient  in  a  stand- 
ing position. 

Although  such  an  event  is,  of  course,  rare,  drawing  off  the  en- 
tire contents  of  the  bladder  allows  the  enlarged  blood-vessels  which 
have  been  accustomed  to  the  support  of  a  certain  amount  of  fluid  to 
collapse,  a  transudation  of  blood  follows;  so  much  so  that  a  great 
deal  of  hsemorrhage  may  occur,  and  the  existing  cystitis  is  always 
made  worse. 

If  the  bladder  is  considerably  distended,  it  is  always  better  to 
leave  one-half  or  one-fourth  of  its  contents  in  it,  or  to  inject  six 
or  eight  ounces  of  warm  salt  or  borax  solution  and  leave  it  in. 

GENERAL  TREATMENT. 
In  all  cases  of  prostatic  hypertrophy  hygienic  measures  are  very 
important  in  preventing  attacks  of  retention  of  urine.    The  patient 
should  wear  flannel  underclothing  in  winter,  and,  as  the  circulation  of 


196 


DISEASES  OF  THE  PROSTATE. 


blood  is  poor  in  the  feet  and  they  are  the  parts  most  easily  chilled, 
woolen  stockings  should  be  worn. 

He  should  avoid  any  overindulgence  in  alcohol  or  malt  liquors, 
although  a  glass  or  two  of  claret  or  a  little  whisky  may  be  permitted. 

The  bowels  ought  to  receive  due  attention,  and  constipation 
should  be  guarded  against.  Any  overdistension  of  the  bladder  wdth 
retained  urine  has  the  effect  of  still  further  weakening  the  atonic 
muscular  walls,  and  on  this  account  the  patient  should  be  instructed 
to  pass  his  water  at  regular  intervals,  two  to  four  hours  apart. 

In  the  early  stages  of  prostatic  h5'pertrophy,  when  the  enlarge- 
ment is  only  moderate  in  size  and  not  very  dense,  and  when  the  quan- 
tity of  residual  urine  is  small,  the  chief  source  of  annoyance  to  the 
patient  is  from  the  irritability  of  the  bladder,  which  causes  a  frequent 
desire  to  urinate. 

Such  cases  are  often  benefited  by  the  passage  of  a  large-sized 
steel  sound,  w-hich  relieves  the  irritability  of  the  bladder  and  over- 
comes the  muscular  spasm  of  the  urethra.  The  action  of  the  sound 
is  to  press  out  and  empty  the  engorged  venous  plexus  around  the 
prostate,  and  while  it  does  not  prevent  the  increase  in  size  of  the 
gland,  it  seems  at  least  to  retard  its  growth.  The  sound  should  be 
used  once  in  every  five  days,  and  allow^ed  to  remain  lying  in  the 
urethra  from  ten  to  fifteen  minutes  at  a  time. 

The  presence  of  residual  urine  offers  an  important  indication 
for  treatment. 

If  the  residual  urine  is  only  one  or  two  ounces  in  quantity  and 
clear  in  color, -it  is  only  necessary  to  pass  the  catheter  once  in  four 
to  eight  w^eeks,  in  order  to  observe  the  progress  of  the  case  and  ascer- 
tain that  the  obstruction  is  not  becoming  greater  or  the  atony  of  the 
bladder-wall  increasing. 

In  time,  however,  the  residual  urine  increases  in  amount,  and, 
when  it  reaches  three  or  four  ounces  in  quantity,  the  catheter  should 
be  employed  once  a  day  to  remove  it  from  the  bladder,  a  convenient 
working  rule  (if  the  urine  is  sterile)  being  to  use  the  catheter  once 
daily,  preferably  at  bed-time,  for  three  ounces,  twice  daily  for  six 
ounces,  and  then  once  more  for  every  additional  two  ounces.  With 
sterile  urine  it  is  rarely  necessary  to  catheterize  oftener  than  once  in 
four  hours. 

Unfortunately,  however,  the  bladder  rarely  escapes  infection 
for  any  length  of  time  after  beginning  catheterization,  and  then  a 
new  element  is  introduced  into  the  case:   that  of  cystitis.     Inflam- 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  I97 

mation  of  the  bladder  is  generally  ushered  in  by  some  rise  in  tem- 
perature, which  may  run  for  a  few  days  and  subside  or  may  continue 
for  some  length  of  time,  as  a  result  of  absorption  into  the  blood  of 
septic  material. 

The  frequency  of  the  desire  to  urinate  is  notably  increased,  and 
the  urine  contains  pus  and  in  the  early  stages  blood  may  be  present. 

The  fermentative  changes  in  the  urine  rapidly  cause  its  decom- 
position, and  it  becomes  strongly  alkaline  in  reaction  and  ammoniacal 
in  odor. 

After  cystitis  has  lasted  for  a  short  time  the  contractility  of  the 
muscular  fibres  of  the  bladder-walls  is  still  more  impaired,  and  the 
residual  urine  increases  in  quantity,  so  that  the  catheter  has  to  be 
used  more  frequently,  in  order  to  prevent  the  accumulation  of  urine, 
which  is  stagnant  and  soon  decomposes. 

The  indications  for  the  treatment  of  this  condition  may  be 
summed  up  as  follows: — 

(a)  Drain  the  bladder  of  residual  urine. 

(&)  Keep  it  as  clean  and  aseptic  as  possible,  and  check  decompo- 
sition of  the  urine  by  means  of  bladder-washing  and  the  administra- 
tion of  urinary  antiseptics  by  the  mouth.   • 

For  the  treatment  of  the  cystitis  the  reader  is  referred  to  the 
chapter  on  the  treatment  of  "Chronic  Cystitis." 

The  ordinary  routine  treatment  of  a  case  of  prostatic  hyper- 
trophy, consisting  in  bladder-washing  and  daily  catheterization,  can 
be  readily  carried  out  by  the  patient  himself,  if  he  is  moderately  in- 
telligent, after  he  has  been  instructed  by  his  attending  physician. 

The  best  form  of  catheter  for  him  to  use  is  the  soft-rubber  in- 
strument, and,  indeed,  every  patient  with  enlarged  prostate  should 
be  familiar  with  the  method  of  passing  the  catheter  and  should  keep 
one  at  hand,  as  he  is  always  liable  to  an  attack  of  retention  of  urine 
from  some  slight  cause,  and  unless  prompt  relief  can  be  obtained 
the  bladder-wall  may  suffer  irreparable  damage  from  the  distension 
and  stretching  caused  by  the  accumulation  of  urine. 

An  important  part  of  the  instruction  of  the  patient  consists  in 
teaching  him  the  proper  method  for  the  care  of  the  catheter.  This 
is  a  very  material  point  in  the  management  of  the  case,  and,  if  cystitis 
is  not  already  established,  the  frequent  use  of  the  catheter  generally 
induces  it,  unless  the  greatest  care  to  avoid  infection  is  taken  by 
means  of  scrupulous  cleanliness. 

It  is  not  difficult  to  cleanse  the  outside  of  the  catheter,  but  the 


198  DISEASES  OF  THE  PROSTATE. 

interior  is  its  most  dangerous  part,  on  account  of  the  difficulty  of 
disinfecting  it. 

After  using  the  catheter  a  stream  of  hot  water  should  be  allowed 
to  run  through  it  from  a  faucet  or  forced  through  with  a  syringe, 
in  addition  to  scrubbing  off  the  outside  with  soap  and  water.  But 
even  this  is  not  sufficient  to  remove  all  the  accumulations  of  pus  and 
urine,  etc. 

Boiling  the  catheter  in  plain  water  is  a  perfect  means  of  dis- 
infecting the  soft-rubber  instruments,  and,  by  having  a  number  of 
them,  they  can  all  be  boiled  at  once  and  laid  away  in  clean  towels 
and  a  fresh  one  taken  for  each  catheterization. 

The  formalin  sterilizing  cabinet  also  affords  a  reliable  means  of 
disinfecting,  both  the  soft-rubber  and  the  gum-elastic  instruments, 
after  first  scrubbing  and  allowing  water  to  flow  through  them,  and 
the  plan  of  sterilizing  a  number  of  instruments  at  the  same  time  may 
be  adopted. 

These  methods,  however,  cannot  always  be  applied  to  every  case, 
as  in  the  instance  of  travelers,  who  cannot  carry  the  necessary  steril- 
izing outfit.  In  such  cases  the  catheter  may  be  kept  sterile  by  im- 
mersing it  in  a  bottle  of  carbolic-acid  solution  from  2  to  5  per  cent., 
after  washing,  and  allowing  it  to  remain  there. ^ 

In  every  case  the  catheter  should  be  frequently  inspected,  and 
discarded  at  once  when  it  becomes  dry  and  cracked. 

At  the  time  the  patient  is  instructed  as  to  taking  care  of  his 
catheter  he  should  also  be  taught  to  wash  the  glans  penis  with  a 
cotton  sponge  and  soap  and  water  every  time  before  the  catheter  is 
introduced,  in  order  to  avoid  carrying  micro-organisms  into  the 
urethra  from  the  head  of  the  penis. 

But  in  spite  of  all  precautions  it  is  most  exceptional  for  the 
urine  to  remain  clear,  and,  as  a  rule,  a  slight  degree  of  cystitis  is 
continually  present.  On  this  account  and  to  lessen  the  tendency  to 
the  formation  of  calculus,  it  is  very  desirable  that  the  patient  should 
use  irrigation  of  the  bladder  once  or  twice  each  day. 


^  The  following  solution  is  now  being  used  in  Berlin  for  sterilizing  gum- 
elastic  catheters: — 
R  Glycerin, 

Water    of  each  Sviij. 

Corrosive  sublimate gr.  viij. 

After  six  hours'  immersion  laboratory  experiments  show  the  catheter  to 
be  sterile,  and  prolonged  immersion  in  the  fluid  does  not  roughen  or  crack  the 
surfaces. 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  I99 

This  can  be  very  readily  done,  at  the  time  he  uses  the  catheter, 
by  means  of  a  rubber  douche-bag  or  fouutain-syfinge  raised  up  three 
feet  high  and  attached  by  its  tube  to  the  end  of  the  catheter.  The 
mild  solutions,  either  boric  acid,  salt  solution,  or  permanganate  of 
potash  are  suitable  for  this  purpose. 

Commencement  of  Catheter-life. — In  cases  of  prostatic  hyper- 
trophy where  there  is  little  or  no  cystitis  and  the  quantity  of  residual 
urine  is  only  from  four  to  six  ounces,  if  due  precautions  are  taken 
to  guard  against  cystitis,  the  patient  very  soon  becomes  accustomed 
to  the  use  of  the  catheter.  But,  in  those  instances  where  the  residual 
urine  amounts  to  ten  ounces  or  more,  a  considerable  amount  of 
constitutional  disturbance  usually  follows  the  first  catheterization. 
Urinary  fever  generally  occurs,  and,  if  the  kidneys  were  previously 
diseased  and  the  patient  is  very  old  and  feeble,  it  is  by  no  means  rare 
for  the  case  to  terminate  by  death. 

It  is  desirable,  then,  before  beginning  catheterization,  in  the  pres- 
ence of  large  quantities  of  residual  urine,  to  warn  the  patient  that 
there  is  some  risk  attached  to  the  procedure,  and  to  insist  that  he 
shall  remain  quietly  at  his  home  and  for  the  most  part  in  bed  for 
a  fortnight.  During  that  time  the  urine  should  be  drawn  by  the 
catheter  three  or  four  times  a  day  and  from  four  to  six  ounces  of 
boric-acid  solution  thrown  into  the  bladder  each  time  that  the  urine 
is  withdrawn,  so  that  the  bladder  will  not  be  left  entirely  empty. 

Urinary  antiseptics  should  be  given  by  the  mouth,  but  it  is 
better  to  avoid  washing  out  the  bladder  for  the  first  week  or  so,  until 
a  certain  degree  of  tolerance  is  established.  Under  these  precautions 
the  advanced  cases  of  prostatic  hypertrophy  with  an  excess  of  residual 
urine  are  introduced  into  catheter-life  with  a  minimum  degree  of 
risk.  But  even  in  spite  of  all  care  patients  who  are  old  and  feeble, 
and  are  suffering  from  chronic  Bright's  disease  or  pyelitis,  sometimes 
develop  a  chronic  form  of  urinary  fever,  induced  by  the  beginning 
of  catheter-life,  which  terminates  fatally. 

In  these  instances  death  would  have  resulted  from  the  kidney 
disease,  in  any  case,  after  a  short  time,  and,  had  the  use  of  the 
catheter  been  commenced  at  an  earlier  period  in  the  disease,  the 
secondary  involvement  of  the  kidneys  would  have  been  avoided. 

Retention  of  Urine. — Most  old  men  with  enlarged  prostates  suf- 
fer at  some  time  in  their  lives  with  an  attack  of  acute  retention 
of  urine,  from  spasm  of  the  cut-off  muscle  and  swelling  of  the  mucous 
membrane  at  the  vesical  outlet.     Such  a  condition  calls  for  prompt 


200 


DISEASES  OF  THE  PROSTATE. 


catheterization.  The  use  of  prolonged  hot  baths  and  a  full  dose  of 
opium,  which  so  often  relieves  a  spasmodic  stricture  in  a  young  man, 
is  not  to  be  recommended  in  retention  of  urine  from  an  enlarged 
prostate.  The  overdistension  of  the  bladder  must  be  relieved  at 
once,  as  the  stretching  of  its  muscular  fibres  induces  a  condition  of 
atony. 

The  form  of  catheter  to  be  selected  depends  upon  the  shape  which 
the  overgrown  prostate  has  assumed.  It  is  often  found  impossible 
to  introduce  a  flexible  soft-rubber  catheter,  and  it  is  necessary  to  try 
various  shapes,  until  one  is  found  which  will  override  the  obstruction 
offered  by  an  enlarged  middle  lobe  or  an  adenomatous  tumor  which 
deflects  the  urethra  to  one  side. 

The  form  of  catheter  which  is  most  frequently  serviceable  is  the 
Mercier  catheter,  with  the  end  turned  up  (coude).  The  angled  end 
usually  slips  up  past  an  enlarged  middle  lobe  and  enters  the  bladder. 
The  catheter  bicoude  acts  in  a  similar  manner  and  is  useful  when  the 
overgrowth  of  the  middle  lobe  is  excessive. 


Fig.  71. — Meicier  Catheter  Coude. 

The  silver  prostatic  catheter,  with  a  long  beak  and  an  exaggerated 
curve,  is  especially  designed  to  fit  the  elongated  sweep  of  the  urethra 
distorted  by  the  prostatic  overgrowth,  and  is  frequently  successful  in 
reaching  the  bladder.  When  it  fails  to  enter  the  bladder  the  follow- 
ing manipulation  is  often  successful:  The  surgeon  has  provided  him- 
self beforehand  with  a  common  English  catheter  with  a  stylet,  which 
has  been  previously  prepared  by  giving  it  an  exaggerated  curve,  and 
it  is  then  laid  away  until  needed.  When  it  is  wanted,  the  stylet  is 
withdrawn  and  the  catheter  is  introduced  into  the  urethra.  The 
warmth  of  the  body  causes  the  curve  to  increase,  and  the  point  of 
the  instrument  overrides  the  obstruction.  The  catheter  may  also  be 
introduced  with  the  stylet  in  it  down  to  the  prostatic  urethra.  When 
it  reaches  this  point  the  stylet  is  withdrawn  and  the  point  of  the  in- 
strument curves  around  the  enlarged  prostate. 

In  the  manipulations  with  the  silver  and  English  catheters  due 
care  should  be  used  not  to  make  a  false  passage  in  the  swollen  tissues 
around  the  prostate.    The  attempts  to  reach  the  bladder  with  a  filiform 


SENILE  HYPERTROPHY  OF  THE  PROSTATE.  3OI 

guide  and  a  tunneled  sound  threaded  over  it  are  of  very  little  use 
except  in  cases  of  stricture. 

A  bladder  which  is  full  and  distended,  if  it  has  been  so  for 
more  than  a  few  hours,  should  never  he  completely  emptied  at  one 
sitting,  but  six  or  eight  ounces  of  urine  or  boric-acid  solution  should 
be  left  in  it,  to  support  the  blood-vessels  and  give  the  muscles  some- 
thing to  contract  on. 

If  all  attempts  to  enter  the  bladder  are  unavailing,  in  order  to 
relieve  the  retention  it  is  necessary  to  have  recourse  to  suprapubic 
aspiration  of  the  bladder. 

The  needle  attached  to  the  aspirator  is  thrust  directly  down- 
ward, a  finger's  breadth  above  the  pubes,  and  penetrates  the  bladder 
without  wounding  the  peritoneum,  as  when  the  bladder  is  distended 
the  fold  of  peritoneum  covering  it  is  raised  up  two  and  one-half 
inches  above  the  pubes. 

Aspiration  affords  prompt  relief;  but,  while  the  bladder  has  been 
emptied  for  the  space  of  a  week  by  means  of  repeated  aspirations,  it 
cannot  be  done  with  safety  more  than  a  few  times. 

Suppuration  often  results  after  three  or  four  tappings,  or  the 
bladder-wall  becomes  soft  and  leaks;  so  that  aspiration  can  only  be 
depended  on  as  a  temporary  expedient,  for  a  day  or  two. 

In  certain  cases  of  enlarged  prostate,  which  are  suffering  from 
chronic  retention,  it  is  desirable  to  keep  the  bladder  empty  and  at 
the  same  time  avoid  the  frequent  introduction  of  a  catheter;  to  attain 
this  end  continuous  catheterization  is  accomplished  by  introducing  a 
soft-rubber  catheter  into  the  bladder  and  tying  it,  so  that  it  cannot 
be  forced  out. 

The  indications  for  the  use  of  continuous  catheterization  are  sum- 
marized by  J.  W.  White  as  follows: — 

(a)  When  great  difficulty  is  experienced  in  introducing  the 
catheter. 

(b)  When  much  bleeding  follows  the  introduction  of  the  catheter, 
as  is  generally  the  case  when  unsuccessful  attempts  at  catheterization 
have  been  made  before. 

(c)  When  much  cystitis  with  purulent  or  ammoniacal  urine  exists 
and  the  frequent  passage  of  a  catheter  is  impracticable  on  account  of 
the  pain  and  hjemorrhage  which  it  produces. 

By  means  of  continuous  catheterization  the  bladder  is  drained 
and  readily  washed  out,  and  a  general  improvement  in  the  symptoms 
takes  place. 


CHAPTER  XIV. 

OPERATIVE  TREATMENT  OF  HYPERTROPHIED  PROSTATE. 

The  removal  of  the  obstruction  offered  by  au  enlarged  prostate, 
by  means  of  a  surgical  operation,  is  not  to  be  thought  of  in  patients 
who  have  but  a  small  quantity  of  residual  urine  and  little  or  no  cys- 
titis, and  when  catheterization  is  easy  and  not  accompanied  by  pain  or 
bleeding.  In  many  instances  the  patient  can  be  made  entirely  com- 
fortable throughout  his  life  by  regular  catheterization. 

In  some  cases,  however,  when  the  catheter  has  been  used  for  a 
long  time,  the  prostatic  hypertrophy  increases  in  size,  the  contractile 
power  of  the  bladder  lessens,  the  cystitis  grows  worse,  and  the  pres- 
ence of  a  small  quantity  of  urine  in  the  bladder  causes  extreme  tenes- 
mus until  it  is  removed.  As  a  result  of  the  frequent  demands  for 
urination,  the  catheter  has  to  be  passed  so  often  that  the  urethra  be- 
comes irritable  and  bleeds  freely,  and  the  cystitis  grows  progressively 
worse.  In  the  expressive  words  of  J.  W.  White  the  condition  of  the 
patient  is  that  of  "approaching  break-down  in  catheter-life."  These 
are  all  indications  that  catheterization  will  soon  have  to  be  discon- 
tinued and  some  other  means  of  draining  the  bladder  adopted. 

Indeed,  all  of  the  surgical  operations  for  prostatic  hypertrophy 
are  directed  to  the  one  end  of  draining  the  Madder,  either  through  the 
removal  of  the  obstructing  portion  of  the  prostate  or  by  means  of  an 
artificial  permanent  fistula. 

A  list  of  the  operations  may  be  tabulated  as  follows: — 

Radical  Operations. — 

Bottini's  Operation. 

Perineal. 


Prostatotomy   ^   ^  ,  . 

'  buprapubic. 

r  Suprapubic, 
Prostatectomy  J  Perineal,  or 

I  Combination  of  both. 
Vasectomy. 
Castration,  or  Orchidectomy, 

Palliative  operations,  in  which  no  part  of  the  prostate  is  removed, 
are  only  undertaken  for  the  purpose  of  draining  the  bladder  through  a 
fistulous  opening: — 
(202) 


BOTTINI'S  OPERATION.  203 

(a)  Perineal  cystotomy  and  drainage  through  a  catheter  retained 
in  the  bladder. 

(b)  Suprapubic  cystotomy, 

(c)  Puncture  through  the  substance  of  the  prostate  with  a  trocar. 


BOTTINI'S  OPERATION. 

Bottini's  operation  consists  in  burning  channels  through  the  en- 
larged prostate  by  means  of  a  specially-devised  instrument,  heated 
with  the  electric  current,  and  introduced  into  the  bladder  through 
the  urethra.  The  instrument  was  devised  by  Bottini,  of  Pavia,  Italy, 
and  used  by  him  for  over  twenty  years. 

Description  of  Instrument.  —  The  instrument  is  shaped  like  a 
lithotrite,  and  is  provided  with  a  thin  platino-iridium  blade,  which  is 
concealed  when  the  instrument  is  closed,  and  is  moved  backward  or 


^^ 


Fig.  72. — Bottini's  Instrument,  as  Modified  by  Freudenberg. 

forward  in  a  slot  in  the  shaft  by  turning  a  wheel  at  the  end  of  the 
instrument.  This  blade  is  heated  to  a  dull  cherry  red  by  means  of 
an  electric  current  conducted  to  it  from  a  storage  battery,  through  a 
cord  attached  to  the  extreme  end  of  the  instrument.  All  parts  of  the 
instrument,  except  the  blade,  are  prevented  from  becoming  heated 
by  a  stream  of  cold  water,  which  constantly  circulates  through  it. 

Technique  of  Operation. — General  anesthesia  is  not  required;  a 
4-per-cent.  solution  of  cocaine  is  introduced  into  the  posterior  urethra, 
after  first  washing  the  bladder  with  boric  acid  and  letting  it  run  out 
again  through  the  catheter.  Bottini's  instrument  is  introduced  into 
the  bladder  and  hooked  up  against  the  projection  of  the  middle  lobe. 
The  cold-water  stream  is  turned  on,  and  when  everything  is  in  readi- 
ness the  electric  current  is  switched  on,  a  pause  of  ten  seconds  is  made 
for  the  blade  to  become  hot,  and  then  the  wheel  is  slowly  turned, 
causing  the  red-hot  blade  to  slide  out  from  its  place  of  concealment 
and  slowly  burn  its  way  through  the  tissues  of  the  prostate.     After 


204  DISEASES  OF  THE  PROSTATE. 

the  incision  has  been  made  deep  enough  the  wheel  is  reversed,  and 
the  blade  is  slid  back  into  its  place  of  concealment,  charring  for  a 
second  time  the  tissues  of  the  incision,  and  then  the  electric  current 
is  turned  off. 

An  anterior  cut  is  made  in  the  same  way  and  a  lateral  cut  through 
the  lobe  which  is  apparently  most  enlarged. 

The  length  of  the  incisions  depends  upon  the  size  of  the  prostate, 
but,  as  a  rule,  three  centimetres  are  sufficient  for  the  posterior  cut 
and  two  centimetres  for  the  lateral  cuts. 

The  after-ireatment  consists  in  keeping  the  patient  in  bed  and 
passing  a  catheter  if  there  is  retention  of  urine. 

Haemorrhage  is  a  rare  accident,  but  can  be  controlled  by  the  press- 
ure of  a  large-sized  catheter  tied  in  the  bladder. 

It  is  not  necessary  to  pass  sounds,  as  the  cuts  show  no  tendency 
to  close  up. 

The  sloughs  usually  separate  about  the  eighth  to  the  fourteenth 
day,  and  some  slight  bleeding  occurs;  and  if  the  operation  has  been 
successful  in  severing  the  obstruction  the  urine  begins  to  flow  freely. 

The  maximum  of  improvement  is  not  attained,  however,  until 
after  four  weeks  have  passed,  as  by  that  time  the  bladder  has  recov- 
ered its  tone  to  some  degree,  and  the  cicatrices  in  the  prostate,  formed 
by  the  healing  of  the  incisions,  have  begun  to  contract  and  open  up 
the  passage. 

Selection  of  Cases. — Bottini's  operation  appears  to  be  contra- 
indicated  in  the  cases  of  very  large  prostates  the  size  of  a  small 
apple  or  larger,  as  the  instrument  can  scarcely  burn  a  furrow  in  them 
deep  enough  to  overcome  the  obstruction. 

It  is  particularly  adapted  to  the  small,  hard,  fibrous  prostates 
where  there  is  a  decided  bar  at  the  neck  of  the  bladder. 

The  advantages  of  the  operation  are  that: — 

(a)  No  anresthetic  is  required,  and  it  is  not  accompanied  with 
great  pain. 

(&)  It  is  comparatively  free  from  danger  to  life. 

(c)  It  is  applicable  to  the  hard,  fibrous  prostates  which  cannot  be 
successfully  removed  by  prostatectomy  and  which  do  not  atrophy  after 
castration. 

Besults,  as  shown  by  Wossidlo's  statistics: — 

Cases.  Cprf.d.  Imtroted.  No  Rp^pi.t.  Dkaths. 

110      65         16  20  9 

59  per  cent.  13.6  per  cent.  18.2  per  cent.  8.2  per  cent. 


PROSTATECTOMY.  205 


PROSTATOTOMY. 

By  the  terra  of  prostatotomy  is  understood  the  simple  division 
of  a  middle  lobe,  or  cutting  off  a  prominence  which  juts  out  like  a 
nipple  and  projects  into  the  bladder,  or  the  cutting  of  a  V-shaped 
piece  out  of  the  prostate,  in  order  to  get  a  low-level  channel  from 
the  bladder. 

Prostatotomy  may  be  performed  by  means  of  an  opening  into  the 
bladder  made  above  the  pubes,  but  the  perineal  route  is  the  one  usually 
selected. 

If  the  prostate  is  not  more  than  three  inches  thick,  it  is  possible, 
by  means  of  an  opening  in  the  perineal  urethra,  to  reach  a  projecting 
middle  lobe,  which  may  be  readily  divided  with  a  knife,  or,  if  it  has 
assumed  a  nipple-like  form,  can  be  snipped  off  with  scissors  or  an 
ecraseur. 

It  is  rarely  possible  by  means  of  a  simple  prostatotomy  to  remove 
enough  of  the  overgrowth  of  prostatic  tissue  to  relieve  the  symptoms 
of  obstruction,  and  the  chief  advantage  which  follows  is  from  the 
benefit  which  the  patient  derives  from  the  prolonged  drainage  of  the 
urethra  through  a  catheter  and  the  attendant  improvement  of  the 
cystitis. 

According  to  Watson,  50  per  cent,  of  cases  subjected  to  perineal 
prostatotomy  had  a  restoration  of  the  function  of  the  bladder  and  10 
per  cent.  died. 


PROSTATECTOMY. 

In  this  operation  the  entire  substance  of  the  prostate  is  enu- 
cleated from  its  capsule  and  removed  through  an  incision. 

Perineal  Prostatectomy. — As  a  result  of  the  experience  gained  in 
prostatotomies,  in  which  a  projection  from  a  median  lobe  was  torn  off 
or  a  V-shaped  piece  was  cut  out  of  it,  the  next  step  in  the  develop- 
ment of  the  operation  was  to  enucleate  the  entire  gland  through  a 
perineal  incision. 

In  this  operation,  as  it  was  done  originally,  the  prostate  was  ap- 
proached through  a  median  perineal  incision  by  which  the  urethra  was 


206  DISEASES  OF  THE  PROSTATE. 

opened  into,  as  in  external  urethrotomy.  The  wound  thus  made,  how- 
ever, was  too  limited  in  extent  to  afford  ready  access  to  the  gland,  and 
a  transverse  perineal  incision  two  and  one-half  inches  in  length  and 
curving  around  the  rectum  was  adopted. 

In  one-third  of  the  cases  it  was  found,  at  the  time  of  operation, 
that  the  distance  from  the  junction  of  the  membranous  and  prostatic 
urethra  to  the  most  distant  point  of  the  median  enlargement  within 
the  bladder  was  more  than  three  inches,  and  consequently  the  prostate 
was  located  out  of  reach  of  the  finger,  and  enucleation  was  impracti- 
cable. 

To  obviate  this  difficulty  Alexander  and  Nicoll  practice  making 
a  suprapubic  incision  into  the  bladder,  and,  by  means  of  two  fingers 
introduced  into  the  bladder,  press  the  prostate  down,  so  that  it  can  be 
easily  reached  through  a  median  incision  in  the  perineum. 

The  advantage  of  opening  the  bladder  above  the  pubes  is  not 
alone  to  press  down  the  prostate  so  that  it  can  be  reached  from  below, 
but  an  opportunity  is  afforded  to  examine  the  cavity  of  the  bladder 
thoroughly  with  the  finger  and  to  search  for  and  remove  a  calculus, 
if  present.  If  the  stone  should  happen  to  be  located  in  a  saccular 
dilatation  of  the  bladder,  it  would  be  impossible  to  remove  it  in  any 
other  way. 

Technique  of  Alexander's  Operation  of  Perineal  Prostatectomy 
Combined  with  Suprapubic  Cystotomy. — The  bladder  is  first  opened 
by  moans  of  a  suprapubic  cystotomy.  The  patient  is  then  placed  in 
the  lithotomy  position,  and  a  grooved  staff  introduced  through  the 
urethra  into  the  bladder.  The  membranous  urethra  is  opened  upon 
the  staff  by  means  of  a  median  perineal  incision.  The  forefinger  of 
the  surgeon's  left  hand  is  then  passed  through  the  suprapubic  wound 
in  the  bladder,  and  presses  the  prostate  downward  into  the  perineum. 
The  forefinger  of  the  right  hand  is  introduced  through  the  perineal 
wound  into  the  prostatic  urethra,  and  its  mucous  membrane  is  torn 
through  at  one  side.  The  finger  is  pushed  through  the  opening  thus 
made,  and  enucleates  one  of  the  lateral  lobes  of  the  prostate.  The 
piece,  after  it  is  enucleated,  can  be  seized  with  forceps  and  with- 
drawn through  the  perineal  wound. 

The  finger  is  then  reintroduced,  and  the  lateral  lobe  of  the  other 
side  and  the  middle  lobe  are  enucleated  and  removed  in  the  same  way. 
The  only  part  of  the  urethra  which  is  torn  lies  in  front  of  the  ejacula- 
tory  ducts.  The  perineal  wound  is  drained  through  a  large  catheter 
carried  through  it  into  the  bladder,  and  hsemorrhage  is  controlled  by 


PROSTATECTOIMY. 


207 


a  gauze  packing  around  the  catheter.  A  drainage-tube  is  introduced 
through  the  wound  in  the  bladder,  and  the  bladder-walls  sutured 
around  it.    Both  wounds  are  usually  healed  at  the  end  of  five  weeks. 

The  advantages  which  Alexander  claims  for  his  method  are  as 
follow: — 

"I.  The  entire  obstructing  portions  of  the  prostate  are  thor- 
onghly  removed  through  a  perineal  opening  without  injury  to  the 
mucous  membrane  of  the  bladder  or  of  the  prostatic  urethra  above 
the  opening  of  the  seminal  ducts. 

'TI.  HEemorrhage  is  rarely  a  serious  complication. 

'TIL  The  most  efficient  and  thorough  drainage  of  the  bladder 
is  secured. 

"IV.  The  time  required  by  practiced  hands  to  perform  the  opera- 
tion is  comparatively  short. 

"V.  The  best  conditions  are  left  for  a  return  of  complete  vol- 
untary urination." 

"The  dangers  of  the  operalion  are: — 

"I.  Suppression  of  urine  in  those  cases  in  which  there  is  ad- 
vanced renal  disease. 

'TI.  Hemorrhage,  which  is  rarely  serious  and  can  always  be  con- 
trolled by  packing  the  perineal  wound  with  gauze  about  the  drainage- 
tube. 

"III.  Injury  to  the  rectum.  It  is,  however,  only  necessary  to 
remember  this  danger  to  avoid  it." 

The  results  in  Alexander's  hands  are  as  follow:  Out  of  31  cases 
operated  upon,  3  deaths,  1  partial  success,  and  27  successful  cases,  in 
which  the  vesical  function  was  restored  and  patients  emptied  their 
bladders  completely. 

Suprapubic  Prostatectomy. — The  removal  of  the  prostate  gland 
by  means  of  a  suprapubic  cystotomy  is  considered  by  some  surgeons  to 
possess  certain  advantages  over  the  perineal  operation.  The  patient 
is  saved  any  loss  of  blood  from  the  perineal  incision,  and  the  operation 
can  be  very  rapidly  performed. 

There  is,  however,  great  liability  to  lacerate  the  base  of  the  blad- 
der if  the  prostate  is  at  all  adherent,  but  the  chief  disadvantage  comes 
from  the  urine  soaking  through  the  incision  which  is  made  in  the  base 
of  the  bladder  for  the  purpose  of  enucleating  the  prostate,  and  causing 
suppuration  of  the  surrounding  tissues,  and  the  haemorrhage  is  often 
alarming. 

The  suprapubic  operation  can  only  be  performed  when  the  cavity 


208 


DISEASES  OF  THE  PROSTATE. 


ol"  the  bladder  is  fairly  capacious,  for  when  the  bladder-walls  are  thick- 
ened and  its  cavit}^  very  much  contracted,  this  operation  is  imprac- 
ticable. 

The  operation  of  suprapubic  prostatectomy  as  originally  per- 
formed by  Belfield  and  McGill  has  been  simplified  in  certain  points  by 
Eugene  Fuller. 

Technique  of  Fuller's  Operation. — The  patient  is  laid  flat  upon  his 
back.  The  Trendelenburg  posture  is  not  adapted,  nor  is  Petersen's 
rectal  bag  used.  The  bladder  is  filled  with  ten  ounces  of  boric-acid 
solution,  and  a  rapid  suprapubic  cystotomy  is  made. 

The  location  and  extent  of  the  prostatic  obstruction  is  deter- 
mined by  examination  with  the  left  forefinger.  By  means  of  a  pair 
of  long-handled  scissors,  with  serrated  edges,  slipped  along  the  left 
forefinger  as  a  guide,  an  incision  is  made  through  the  mucous  mem- 
brane of  the  bladder,  which  lies  above  the  prostate. 

The  cut  exposes  the  prostatic  tissue,  and  extends  from  the  mar- 
gin of  the  internal  vesical  opening  of  the  urethra  about  one  and  one- 
half  inches  in  a  backward  direction.  The  serrated  edges  of  the 
scissors  prevent  any  free  hasmorrhage  from  the  incision. 

Firm  counter-pressure  is  made  with  the  fist  against  the  perineum, 
and  the  forefinger  of  the  other  hand  is  slipped  through  the  incision 
in  the  bladder-wall,  and  by  means  of  the  finger  the  entire  prostate  is 
enucleated,  en  masse  or  piece  by  piece,  depending  upon  the  character 
of  the  growth. 

After  the  prostate  has  been  entirely  enucleated  the  patient  is  put 
in  the  lithotomy  position,  an  opening  is  made  into  the  urethra  through 
the  perineum,  and  a  large-sized  rubber  catheter  is  inserted,  through 
it,  into  the  bladder  for  purposes  of  drainage. 

Finally,  after  hot  irrigation,  the  wound  in  the  abdominal  wall  is 
partially  closed  with  silk-worm-gut  sutures,  one  of  which  includes  the 
bladder-wall  at  the  upper  angle  of  the  vesical  incision  and  another  one 
passes  through  the  bladder-wall  at  the  lower  angle  of  the  wound.  In 
this  way  the  bladder  is  kept  in  close  apposition  with  the  abdominal 
wall,  so  that  there  may  be  no  leakage  into  the  space  of  Eetzius.  A 
double  drainage-ttibe  is  inserted  into  the  bladder. 

The  chief  element  of  success  in  this  operation  is  the  rapidity  with 
which  it  is  performed,  and  it  is  also  essential  to  use  the  smallest  quan- 
tity of  ether  with  which  anesthesia  can  be  maintained,  on  account  of 
the  lowered  vitality  attendant  upon  the  age  of  the  patients. 

The  after-treatment  consists  in  careful  and  thorough  vesical  irri- 


PROSTATECTOMY. 


209 


gation  through  the  drainage-tubes  and  the  administration  of  large 
quantities  of  distilled  water  by  the  mouth,  for  its  diuretic  effect. 

In  order  to  guard  against  hypostatic  pulmonary  congestion  from 
lying  in  bed,  the  patient  should  never  be  allowed  to  lie  long  in  one 
position,  but  should  be  carefully  turned  from  side  to  side,  and  the 
shoulders  should  be  elevated  occasionally. 

Results  of  Suprapubic  and  Perineal  Prostatectomy. — At  the  time 
that  the  operation  of  complete  removal  of  the  prostate  first  came  into 
prominence  the  objection  was  raised  by  Guyon,  Socin,  and  Thompson, 
on  theoretical  grounds,  that,  even  though  the  obstructing  prostate  be 
removed,  the  contractile  power  of  the  bladder  has  been  so  much  im- 
paired that  the  patient  will  be  incapable  of  spontaneous  urination  after 
the  operation.  The  tabulated  results  of  150  prostatectomies,  however, 
now  demonstrate  that  in  75  per  cent,  of  the  cases  restoration  of  the 
bladder  function  does  take  place,  and  that  patients  who  were  pre- 
viously dependent  upon  the  catheter  are  enabled  to  urinate  volun- 
tarily again. 

In  spite  of  the  good  results  attained  through  prostatectomy,  there 
are  certain  grave  objections  to  the  operation.  The  subjects  of  en- 
larged prostate  are  always  advanced  in  years,  and,  as  a  rule,  their 
vitality  is  at  a  low  ebb.  Prostatectomy  is  a  serious  operation  and  at- 
tended with  a  very  considerable  amount  of  shock. 

In  the  days  following  the  operation  the  patient  is  exposed  to  the 
dangers  of  ether-pneumonia,  to  which  old  people  are  liable,  and  to  the 
risks  of  septicemia  from  infiltration  of  urine  into  the  wound,  or 
urajmic  poisoning  from  a  failure  of  secretion  on  the  part  of  the 
kidneys. 

On  these  accounts  prostatectomy  should  never  be  undertaken  in 
the  case  of  a  debilitated,  feeble  old  man,  or  in  one  who  has  marked 
atheromatous  degeneration  of  the  arteries. 

Even  in  selected  cases,  although  the  results,  as  far  as  restoration 
of  the  bladder  functions  are  concerned,  are  better  than  after  the  other 
operations,  the  mortality  is  higher,  and  ranges  from  11  per  cent. 
(Predal)  to  20  per  cent.  .(Watson). 

Another  contra-indication  to  prostatectomy  is  a  hard,  fibrous  con- 
dition of  the  prostate.  If  the  prostate  is  in  this  state,  it  is  difficult  or 
impossible  to  enucleate  it,  and  some  other  surgical  procedure  must  be 
adopted. 


210  DISEASES  OF  THE  PROSTATE. 

CASTRATION. 

The  danger  to  life  and  the  difficulty  of  performing  the  various 
operations  of  prostatectomy  have  led  surgeons  to  seek  for  other  means 
of  removing  the  obstructing  prostate. 

In  1893  J.  William  White,  of  Philadelphia,  first  published  the 
results  of  his  experiments,  showing  that  the  removal  of  both  testicles 
caused  an  atrophy  and  shrinking  of  the  prostate. 

Velpeau  and  Sir  Henry  Thompson  called  attention,  years  ago,  to 
the  similarity  between  the  fibromyomata  occurring  in  the  prostate  and 
those  of  the  uterus.  Following  up  this  suggestion,  White  castrated  a 
number  of  dogs,  and  found  that  the  operation  was  in  every  case  fol- 
lowed by  a  rapid  atrophy,  first  of  the  glandular  structures  of  the  pros- 
tate and  then  of  the  muscular  elements. 

The  theoretical  grounds  upon  which  White  accounts  for  the 
diminution  in  size  of  the  prostate  are  as  follow: — 

The  prostate  in  the  man,  although  not  embryologically  the  true 
homologue  of  the  uterus,  is  developed  from  tissues  quite  distinct  from 
those  which  go  to  form  the  urinary  passages. 

The  structure  of  the  prostate  and  the  uterus  is  similar,  as  they 
are  both  hollow  muscular  organs  containing  glandular  follicles. 

The  normal  growth  of  the  prostate  is  in  direct  relation  to  the 
sexual  life  of  the  individual,  and  its  overgrowth  occurs  at  a  period 
when  the  sexual  life  is  fading  out,  but  is  usually  not  extinct. 

The  reproductive  powers  of  life  end  sooner  in  the  female  than 
in  the  male,  and,  on  this  account,  fibroid  tumors  of  the  uterus  appear 
earlier  in  women  than  do  prostatic  growths  in  men. 

The  histology  of  uterine  and  prostatic  growths  are  notably  similar 
in  both  sexes. 

The  uterine  tumors  do  not  appear  after  the  menopause,  and  if 
already  present  undergo  atrophy  with  the  cessation  of  menstruation. 

The  prostate  in  men  does  not  continue  to  increase  in  size  after  a 
certain  time  of  life  is  reached,  but  has  a  tendency  to  grow  smaller. 

In  the  female  removal  of  the  ovaries  causes  the  uterine  fibro- 
myomata to  disappear,  and  the  uterus  itself  undergoes  an  atrophy  as 
well,  and,  in  the  male,  removal  of  the  testicles  has  a  similar  effect  upon 
the  prostate. 

Diminution  in  Size  of  the  Prostate. — The  first  effect  upon  the 
prostate  of  the  removal  of  the  testicles  is  to  cause  a  rapid  disappearance 
of  the  congestion,  which  reduces  the  gland  somewhat  in  size.     This 


CASTRATION. 


211 


slight  reduction  in  bulk  often  relieves  the  obstruction  and  the  patient 
can  sometimes  urinate  spontaneously  a  few  hours  after  the  operation 
of  castration 

The  experiments  on  dogs  and  autopsies  upon  men  have  shown 
that  a  true  atrophy  of  the  gland  takes  place  from  absorption  and  dis- 
appearance of  its  glandular  structure,  which  occurs  first  and  is  fol- 
lowed later  by  the  partial  disappearance  of  the  connective-tissue 
stroma  which  lies  between  the  glandular  elements. 

These  changes  may  require  a  few  weeks  or  from  four  to  six  months 
before  they  are  completed;  so  that  we  should  not  be  disappointed  if 
after  castration  several  months  elapse  before  any  good  results  are 
manifested. 

The  general  indications  for  castration  are  the  same  as  for  any  of 
the  other  operative  procedures,  viz.:  "approaching  break-down  in 
catheter-life." 

Castration,  however,  is  particularly  adapted  to  the  cases  of  large, 
soft,  elastic  prostates,  congested  with  blood  and  containing  a  good  deal 
of  glandular  tissue. 

The  prostates  which  have  advanced  to  the  second  stage  of  hyper- 
trophy, in  which  the  glandular  tissue  has  disappeared  and  has  been 
replaced  by  connective  tissue,  causing  the  prostate  to  become  hard  and 
of  a  dense  consistence,  are  unfavorable  cases  for  castration,  and,  while 
good  results  sometimes  follow  from  the  decongestion  of  the  organ, 
the  fibrous  residue  of  the  prostate  does  not  shrink  after  the  operation. 

Clinical  Results  of  Castration. — Castration  has  now  been  done  for 
the  relief  of  hypertrophied  prostate  in  hundreds  of  cases,  and  the  re- 
sults of  the  operation  have  been  closely  followed  by  many  different 
observers.  The  statistics  of  111  cases  of  castration,  which  were  col- 
lected by  White,  showed  that  a  rapid  atrophy  of  the  prostatic  enlarge- 
ment occurred  in  87  per  cent.  There  was  a  disappearance  or  lessening 
of  the  long-standing  cystitis  in  52  per  cent.,  a  return  of  vesical  con- 
tractility in  66  per  cent.,  and  an  amelioration  of  the  most  troublesome 
symptoms — viz.:  inability  to  pass  water,  frequent  urination,  and  pain- 
ful urination — in  89  per  cent,  of  the  cases. 

It  will  be  noted  that  in  Dr.  AVhite's  table  the  vesical  contractility 
was  restored  in  66  per  cent.    • 

Fenwick  takes  the  ground  that,  if  a  bladder  has  been  crippled 
for  three  years  or  more  by  severe  cystitis  and  entirely  incapable  of 
being  emptied  except  by  the  catheter,  it  is  highly  probable  that,  even 
if  the  prostate  shrink,  after  castration,  the  muscular  fibres  of  the  blad- 


212 


DISEASES  OF  THE  PROSTATE, 


der  will  be  so  atonied  that  the  catheter  can  never  be  dispensed  with, 
although  its  introduction  will  be  easy. 

In  connection  with  this  view  it  is  interesting  to  note  that  Brims 
reports  28  cases  in  which  the  catheter  had  been  used  from  a  few 
months  up  to  two  years  and  in  which  voluntary  urination  was  restored 
in  22  cases. 

In  20  cases  in  which  the  catheter  had  been  used  from  two  to 
twenty  years  spontaneous  urination  returned  in  8  of  them  after  cas- 
tration. 

The  cystitis  is  reported  as  improved  in  52  per  cent,  of  White's 
cases,  and  the  improvement  is  accounted  for  by  the  possibility  of  the 
bladder  being  completely  emptied  of  its  residual  urine,  owing  to  the 
reduction  in  size  of  the  prostate  and  also  from  the  relief  of  the  passive 
hypersemia  in  the  prostatic  plexus  of  veins  and  the  mucous  membrane 
of  the  bladder-walls. 

In  1897  Englisch  published  tabulated  statistics  of  202  cases  of 
castration,  which  had  been  performed  by  various  surgeons.  Of  these, 
in  147  only  were  the  details  stated  with  sufficient  fullness  to  make 
them  worthy  of  record.  Englisch  finds  that  the  age  of  the  patient  has 
but  little  influence  upon  the  result,  but  the  amount  of  prostatic  ob- 
struction, the  quantity  of  residual  urine,  and  the  state  of  the  kidneys 
bear  a  direct  relation  to  the  mortality  of  the  operation.  In  these  oases, 
as  reported,  of  106  patients  operated  upon,  who  suffered  irith  retention 
of  urine,  23  per  cent,  died,  and,  of  18  patients  without  retention,  only 
5  V2  P^r  cent.  died.  The  state  of  the  bladder  and  kidneys  is  a  still 
more  important  consideration  in  the  result.  Of  47  patients  with  se- 
vere cystitis  who  were  castrated,  20  died,  2  were  cured,  and  19  were 
improved;  of  46  patients  with  slight  cystitis,  4  died,  20  were  cured, 
and  20  were  improved.  In  110  cases  a  successful  result  was  shown  by 
reduction  in  size  of  the  prostate  and  an  improvement  in  the  accom- 
panying symptoms  in  69  of  them.  A  reduction  in  the  size  of  the 
prostate  without  an  improvement  of  the  symptoms  was  noted  in  6 
cases,  and  an  improvement  in  the  symptoms  without  reduction  of  the 
size  of  the  prostate  in  27  cases. 

The  mortality  of  castration  was  found  to  be  34  deaths  in  220  cases. 
In  14  of  these  it  was  not  possible  to  attribute  death  to  the  operation, 
and  in  the  other  20  death  was  almost  invariably  due  to  advanced  dis- 
ease of  the  urinary  organs. 

In  1898  Albarran  and  Motz  collected  and  published  statistics. of 
124  castrations.    They  divided  the  cases  into  four  groups: — 


CASTRATION. 


!13 


(a)  Cases  of  dysuria,  hut  u-itlwut  retention.  Of  14  cases  of  pro- 
static hypertrophy  with  these  symptoms,  7  were  cured  and  4  were  im- 
proved. 

(&)  Cases  of  acute  retention.  Of  20  prostatics  with  acute  reten- 
tion, 3  died  soon  after  the  operation  and  the  other  17  quickly  regained 
the  ability  to  empty  the  bladder,  and  did  not  experience  a  relapse. 

(c)  Cases  of  chronic  partial  retention.  Of  41  prostatics  with 
chronic  retention  which  was  not  complete,  4  died  after  castration,  19 
were  cured,  14  were  improved,  and  in  4  the  residual  urine  was  not 
decreased  in  quantity,  but  the  vesical  tenesmus  improved. 

{d)  Cases  of  complete  chronic  retention.  Of  49  prostatics  with 
complete  retention,  10  died  after  the  operation,  20  were  entirely  cured, 
14  had  a  partial  return  of  spontaneous  urination,  and  in  5  there  was 
no  result. 

In  the  acute  cases  of  retention  and  dysuria  the  good  results  are 
attributed  to  the  relief  of  the  congested  state  of  the  prostate,  and  in 
the  patients  with  chronic  retention  a  diminution  in  the  size  of  the 
prostate  is  brought  about  and  at  the  same  time  the  contractility  of 
the  bladder  is  increased. 

It  should  be  borne  in  mind  that  improvernent  does  not  follow 
after  every  castration,  and  it  is  generally  conceded  that  the  hard, 
flhrous  prostates  are  the  ones  which  do  not  atrophy  after  a  removal  of 
the  testicles. 

A  careless  diagnosis  is  responsible  for  a  certain  number  of  failures. 

Various  local  conditions,  such  as  a  narrow  meatus,  a  long  prepuce, 
stricture  of  the  urethra,  and  particularly  a  vesical  calculus,  all  pro- 
duce symptoms  resembling  those  resulting  from  an  enlarged  prostate, 
and,  indeed,  may  be  present  as  complications.  Therefore  before  pro- 
ceeding to  advise  a  castration  all  such  conditions  should  be  excluded 
by  appropriate  examination. 

The  ease  and  rapidity  with  which  castration  can  be  performed 
has  also  led  to  its  being  used  as  a  last  resource  to  relieve  the  distress 
of  old  men,  who  were  nearly  moribund  and  who  were  unfit  to  stand 
the  slightest  form  of  operative  procedure.  In  such  cases,  of  course, 
no  relief  can  be  expected  from  a  castration,  and  the  patient's  inevi- 
table death  is  only  hastened. 

Mortality  of  Castration. — On  examining  the  statistical  tables  the 
death-rate  of  castration  seems  surprisingly  high  for  such  a  simple 
operation.  Of  the  154  cases  collected  by  Englisch,  16  per  cent,  died, 
14  per  cent,  of  Albarran  and  Motz's  154  cases  died,  and  18  per  cent, 
of  White's  111  cases  resulted  fatally. 


214  DISEASES  OF  THE  PROSTATE. 

This  high  death-rate  may  be  explained  by  the  fact  that  a  number 
of  patients  were  operated  upon  who  were  in  a  urasmic  or  even  dying 
condition.  White  states  that  13  of  the  fatal  cases  in  his  report  died 
from  existing  kidney  disease,  and,  if  these  are  deducted,  it  will  leave  a 
death-rate  of  only  7  or  8  per  cent.,  which  he  considers  the  legitimate 
mortality  of  castration.  This  view  is  also  borne  out  by  Englisch's 
tables.  In  106  cases  which  he  collected  and  who  suffered  from  reten- 
tion of  urine,  23  per  cent,  died;  while,  of  18  patients  castrated  who 
had  no  retention,  the  mortality  was  only  5  ^/g  per  cent. 

His  tables  also  show  the  relation  which  disease  of  the  bladder  and 
kidneys  bears  to  the  mortality.  Of  47  cases  who  had  severe  cystitis, 
42  per  cent,  died;  while,  of  46  cases  with  but  a  slight  degree  of  cys- 
titis, only  8  per  cent,  were  fatal. 

In  Albarran  and  Motz's  cases,  of  the  patients  with  acute  retention 
of  urine,  15  per  cent,  died;  of  those  with  chronic  complete  retention, 
20  per  cent,  died;  while  with  those  of  partial  retention  the  death-rate 
was  only  9  per  cent. 

Remote  Results  of  Castration. — A  small  number  of  patients  after 
being  castrated  developed  delirium,  or  a  condition  resembling  senile 
dementia,  and  it  was  formerly  thought  that  the  removal  of  the  tes- 
ticles was  responsible  for  this  state,  upon  the  supposition  that  the 
testicular  secretion  was  necessary  to  the  mental  vigor  and  equipoise 
of  a  man.  That  view  is  now  abandoned,  and  the  delirium  which  occa- 
sionally follows  a  castration  is  supposed  to  be  either  traumatic  or 
urjemic  in  origin,  as  a  similar  form  of  delirium  is  known  to  occur  at 
times  after  any  surgical  operation  upon  an  aged  person. 

From  the  opportunities  which  have  been  afforded  in  the  Orient, 
from  times  of  earliest  antiquity,  to  observe  the  eunuchs,  it  is  highly 
probable  that  the  mere  removal  of  the  testicles  will  have  but  little 
influence  on  the  mental  force  of  the  man.  Curvan  states  that,  in  the 
East,  the  eunuchs  are  shrewd  and  sagacious  mentally  and  vigorous  in 
body,  with  the  exception  of  those  who  are  degraded  by  practices  of 
sexual  perversion. 


VASECTOMY.  215 


VASECTOMY. 

The  disinclination  of  patients  to  allow  the  removal  of  their 
testicles  has  led  surgeons  to  endeavor  to  cause  an  atrophy  of  the 
prostate  by  means  of  ligating  the  spermatic  cord  through  an  incision 
in  the  scrotum. 

Experiments  on  animals  show  that,  when  the  spermatic  cord  is 
divided,  the  prostate  sometimes  grows  smaller.  The  decrease  in  size 
is  accounted  for  by  a  lessening  of  the  congested  condition  of  the  gland, 
which  takes  place  immediately  after  the  operation. 

In  two  anatomico-pathological  examinations  of  prostates  made 
some  time  after  the  operation,  no  atrophy  of  the  gland  was  discernible, 
although  the  contractility  of  the  bladder  had  been  improved  by  the 
operation. 

Albarran  and  Motz  collected  the  following  statistics  of  the  opera- 
tion of  vasectomy:  In  47  cases  7  deaths  followed  the  operation.  A 
diminution  in  the  size  of  the  prostate  occurred  in  21  cases,  which  was 
due  to  the  effect  of  the  operation  in  causing  a  decongestion  of  the 
gland.  In  some  of  the  cases  a  subsequent  examination  showed  that 
the  diminution  in  size  was  only  temporary,  lasting  about  a  month. 
Vasectomy  exerted  little  influence  upon  the  contractile  power  of  the 
bladder.  In  11  cases  of  acute  retention  3  were  cured  and  5  improved. 
In  40  cases  with  dysuria,  or  incomplete  retention,  4  were  cured  and  5 
improved;  and  in  19  cases  of  chronic  complete  retention  3  were  cured 
and  3  improved,  5  died,  and  8  were  without  results. 

From  these  studies  Albarran  and  Motz  conclude  that  resection 
of  the  vasa  deferentia  is  often  followed  by  a  lessening  of  the  congestion 
of  the  prostate,. which  causes  its  volume  to  diminish  temporarily,  and 
evokes  an  improvement  of  the  dysuria,  the  cystitis,  or  the  retention, 
from  which  the  patient  suffers. 

There  is  nothing  to  prove  that  the  operation  causes  an  atrophy  of 
the  hypertrophied  prostate,  or  that  in  cases  of  chronic  incomplete  re- 
tention the  residual  urine  is  diminished  if  the  operation  is  made  at  a 
time  when  the  prostate  is  not  congested.  There  are  also  no  records  to 
show  that  after  the  operation  the  bladder  is  able  to  empty  itself. 


216 


DISEASES  OF  THE  PROSTATE. 


PALLIATIVE  OPERATIONS. 


In  these  operations  no  attempt  is  made  to  remove  any  portion  of 
the  prostate.  They  are  done  for  the  sole  purpose  of  draining  the  blad- 
der, treating  the  cystitis,  and  avoiding  catheterization. 

The  bladder  may  be  drained  by  means  of 

(a)  Perineal  opening,     (h)  Suprapubic  cystotomy. 

The  perineal  incision  is  the  operation  of  choice  when  it  is  desired 
to  drain  the  bladder  temporarily  for  the  sake  of  giving  a  respite  to  the 
urethra  which  has  been  irritated  by  the  hourly  passage  of  a  catheter, 
or  to  remove  blood-clots  from  the  bladder  which  have  originated  from 
ha?morrhage  into  its  cavity. 

In  cases  of  severe  and  obstinate  cystitis  the  perineal  opening  and 
continuous  drainage  serve  to  clear  the  bladder  from  the  thick  muco- 
purulent urine  and  to  restore  the  vesical  mucous  membrane  to  a 
healthy  state  and  the  urine  to  its  normal  acid  reaction. 

The  perineal  incision  is  a  less  serious  operation  than  suprapubic 
cystotomy;  the  danger  to  life  is  not  as  great,  and  an  opportunity  is 
also  ofTered  to  search  the  bladder  with  the  finger,  and,  if  a  small  stone 
is  found,  it  can  be  removed. 

The  prostatic  urethra  is  stretched  and  dilated  with  the  finger  at 
the  same  time,  and  a  large  catheter  is  introduced  through  the  wound 
and  kept  in  the  bladder  for  from  one  to  three  weeks,  draining  it  of 
its  residual  urine  and  allowing  it  to  be  washed  out  and  kept  clean  and 
aseptic. 

The  drainage  of  the  bladder  gives  great  comfort.  The  patient  is 
not  aroused  from  sleep  every  few  minutes  to  pass  water.  The  tenesmus 
and  pain  on  urination  are  no  longer  felt,  the  cystitis  subsides,  and  the 
prostatic  oedema  lessens.  Sometimes  spontaneous  urination  follows. 
After  the  drainage  is  discontinued  the  introduction  of  a  catheter 
becomes  easy. 

Unfortimately,  however,  drainage  through  the  perineum  cannot 
be  kept  up  indefinitely.  The  posterior  urethra  becomes  irritated  and 
resents  the  presence  of  the  catheter  after  a  few  days,  and  so  much  pain 
and  spasm  are  caused  by  it  that  the  catheter  has  to  be  removed. 

In  such  cases,  when  the  drainage  is  still  required,  we  must  have 
recourse  to  another  mode  of  accomplishing  it:   i.e., 

Suprapubic  Cystotomy. — An  opening  made  into  the  bladder  above 
the  pubes  gives  an  opportunity  to  inspect  the  cavity  of  the  bladder  and 


OPERATIONS  FOR  HYPERTROPHIED  PROSTATE.  217 

remove  a  calciilus  if  present,  and  if  the  stone  happens  to  be  in  a  sac- 
cular dilatation  it  can  never  be  found  in  any  other  way. 

The  suprapubic  fistula  answers  very  well  as  a  permanent  opening 
and  is  more  easily  managed  by  the  patient  than  the  perineal  opening. 
A  tube  is  arranged  to  pass  through  the  fistula,  in  the  abdominal  wall, 
into  the  bladder,  siphon  off  the  urine,  and  allow  it  to  (low  into  a 
reservoir  under  the  clothing  (the  Bloodgood  bladder-drain).  The  pa- 
tient wearing  such  an  apparatus  is  able  to  be  up  and  about,  even  to 
take  long  walks  and  enjoy  a  fair  amount  of  activity. 

Puncture  Through  the  Substance  of  the  Prostate  with  a  Trocar. — 
In  cases  where  there  is  an  imperative  necessity  for  draining  the 
bladder,  hut  for  some  reason  the  retention  of  a  catheter  in  the 
urethra  is  impracticable,  drainage  may  be  accomplished  by  plunging 
a  trocar  into  the  perineum  and  through  the  substance  of  the  pros- 
tate, as  suggested  by  Reginald  Harrison. 

A  catheter  is  introduced  into  the  bladder  through  the  cannula 
of  the  trocar  and  left  in,  and  the  cannula  is  withdrawn.  A  serious 
objection  to  this  form  of  tunneling  the  prostate  is  the  danger  of  the 
septic  urine  leaking  into  the  substance  of  the  prostate  through  the 
wound,  and  causing  parenchymatous  suppuration. 


CHOICE  OF  OPERATIONS  IN  HYPERTROPHIED  PROSTATE. 

The  knowledge  which  we  possess  at  the  present  time,  of  the 
relative  worth  of  the  various  operations,  is  too  indefinite  to  enable 
us  to  lay  down  any  hard-and-fast  rules  for  the  selection  of  the 
procedure  best  adapted  to  relieve  a  particular  case. 

There  are  certain  conditions  which  differ  in  each  individual, 
and  which  have  to  be  carefully  considered  before  selecting  the  oper- 
ation which  seems  most  applicable  to  the  case  in  hand. 


POINTS  FOR  CONSIDERATION. 

I.  General  Conditions. — (a)  The  age  of  the  patient. 
(6)  The  state  of  his  general  strength. 

(c)  The  condition  of  his  sexual  powers. 

(d)  The  state  of  his  kidneys. 

(e)  The  amount  of  atheroma  in  the  arteries. 


213  DISEASES  OF  THE  PROSTATE. 

II.  Condition  of  the  Prostate  and  Bladder. — (a)  The  size  and 
density  of  the  prostate. 

(b)  The  form  of  the  obstruction:  whether  it  is  in  the  form  of 
a  bar  across  the  vesical  outlet,  a  tumor  deflecting  the  urethra,  or  a 
mass  the  size  of  an  orange  filling  up  the  pelvis. 

(c)  The  condition  of  the  bladder  in  relation  to  its  atony  or 
hypertrophy. 

{d)  The  quantity  of  residual  urine. 

(e)  Catheterization,  its  ease,  or  if  attended  with  pain  and  bleed- 
ing, and  its  necessary  frequency. 

(/)  The  severity  of  the  accompanying  cystitis. 

III.  Complicating  Conditions. — (a)  Vesical  calculus. 

(b)  Stricture. 

(c)  Diabetes. 

For  the  better  selection  of  an  operation  it  is  useful  to  adopt 
the  classification  of  prostatic  cases  suggested  by  J.  AVilliam  White. 

Class  A. — Patients  with  moderate  enlargement  of  the  prostate, 
who  suffer  little  or  no  pain,  and  with  clear  residual  urine  to  the  ex- 
tent of  three  or  four  ounces.  For  these  cases  no  operation  is  to  be 
thought  of,  and  they  get  on  very  well  with  methodic  catheterism.  But 
in  time,  as  these  difficulties  increase,  they  come  into  Class  B. 

Class  B. — These  patients  suffer  with  marked  obstruction  from 
the  prostatic  overgrowth  at  the  vesical  outlet.  The  prostate  ranges 
in  size  from  one  and  one-half  inches  in  diameter  to  three  inches 
(about  the  size  of  a  lemon).  The  residual  urine  may  be  eight  or 
ten  ounces  in  amount,  or  there  may  be  complete  retention.  The 
cystitis  is  marked,  and  the  urine  is  purulent,  ammoniacal,  and  foetid. 
Operative  interference  of  some  kind  is  clearly  indicated,  and  the 
choice  lies  between  prostatectomy,  castration,  and  Bottini's  opera- 
tion. 

If  the  patient  is  strong  and  vigorous,  with  active  sexual  jj^wers, 
and  is  free  from  atheroma  and  with  sound  kidneys,  and  if  the  hyper- 
trophy is  glandular  in  character,  causing  the  prostate  to  be  soft  and 
elastic  and  of  large  size,  prostatectomy  may  be  considered,  although 
it  should  be  borne  in  mind  that  even  in  skilled  hands  the  death-rate 
ranges  from  11  to  20  per  cent. 

If  the  patient  is  older  and  more  feeble,  and  has  atheroma  or 


OPERATIONS  FOR  HYPERTROPHIED  PROSTATE.       219 

diseased  kidneys,   Bottini's   operation   or   castration   would   be  the 
operation  of  choice. 

Bottini's  operation  appears  to  be  indicated  particularly  in  the 
patients  with  hard,  dense,  fibrous  prostates,  for  castration  has  but 
little  effect  in  causing  this  variety  to  shrink. 

The  soft  elastic  prostates  give  the  best  results  after  castration, 
although  Bottini's  operation  may  be  applied  in  these  cases  also. 

The  choice  between  Bottini's  operation  and  castration  is  some- 
times determined  by  the  form  of  the  obstruction,  which  may  be 
demonstrated  by  a  cystoscopic  examination. 

Class  C. — In  this  class  the  prostate  is  as  large  as  a  base-ball  or 
small  orange.  Eetention  of  urine  is  nearly  or  quite  complete,  and 
catheterization  is  difficult  and  painful.  The  kidneys  are  usually  dis- 
eased, and  atheroma  is  extensive.  In  these  cases  castration  probably 
offers  a  better  chance  of  relief  than  any  of  the  other  operations. 

Class  D  includes  the  desperate  cases  with  enormous  prostates 
and  excessive  cystitis.  The  bladder  is  dilated  and  saccular,  the  re- 
tention complete,  and  catheterism  difficult.  These  patients  are  ad- 
vanced in  years,  and  suffer  from  chronic  urinary  fever.  The  kidneys 
are  diseased,  and  atheroma  is  extreme.  Any  surgical  operation  is  at- 
tended with  great  danger,  but  the  patients'  suffering  is  so  great  that 
they  are  willing  to  accept  any  risk  for  the  sake  of  relief.  In  these 
cases  the  choice  of  operation  would  lie  between  the  establishment 
of  permanent  drainage  of  the  bladder  through  a  fistula,  preferably 
suprapubic,  or  castration. 

Dr.  White  says:  "Castration  offers  more  hope  of  material  benefit, 
with  less  risk,  than  any  other  operation,  although,  of  course,  the 
mortality  is  high.  It  occasionally  fails  to  do  good;  but,  on  the  other 
hand,  I  have  seen  an  improvement  and  many  cases  have  been  re- 
ported that  were  simply  marvelous,  cystitis  vanishing  and  the  power 
of  voluntary  urination  returning  in  patients  in  whom  such  results 
would  have  been  thought  almost  beyond  the  limits  of  possibility." 

Diabetes  is  regarded  as  debarring  all  operations  unless  catheter- 
ization is  impossible.  In  such  cases  permanent  drainage  through 
a  suprapubic  fistula  affords  the  best  means  of  relief. 

For  the  purpose  of  presenting  the  statistical  material  which  has 
been  collected,  in  a  tabular  form,  Wossidlo  has  arranged  the  follow- 
ing table,  in  order  to  compare  the  results  of  the  various  operations: 


220 


DISEASES  OF  THE  PROSTATE. 


Mode  of  Treatment. 


Number 

OF  Cases. 


Cured. 


Im- 

No 

proved. 

Result. 

Percentage. 

Percentage. 

45 

3 

47 

9 

53 

18 

13 

18 

Died. 


Methodical  treatment   . 

Castration 

Vasectomy 

Bijttini's  operation     .     . 


92 
154 
116 
110 


Percentage. 

18 
27 
21 
59 


Percental 

32 

16 

6 


In  the  course  of  time,  as  our  knowledge  is  increased  through 
experience,  it  is  fair  to  assume  that,  by  a  judicious  selection  of  the 
operation  for  each  individual  patient,  we  shall  be  able  to  reduce  the 
number  of  cases  in  which  there  is  no  result  or  but  slight  improve- 
ment, and  that  our  efforts  will  be  more  uniformly  certain  of  complete 
success  than  at  the  present  time. 


CHAPTER  XV. 

TUBERCULOSIS  OF  THE  PROSTATE. 

The  prostate  is  involved  in  nearly  every  case  of  genito-urinary 
tuberculosis.  Of  26  cases  of  tuberculosis  of  the  prostate  reported  by 
Socin,  in  24  of  them  other  genito-urinary  organs  were  affected  and 
only  in  2  did  the  genito-urinary  apparatus  escape.  In  these  two 
instances  the  lungs  and  bones  were  the  seat  of  tubercular  deposits. 

Although  Sir  Henry  Thompson  denied  that  the  prostate  could 
ever  be  the  seat  of  primary  tuberculosis,  later  investigators  have 
proved  conclusively  that  it  may  be,  and  Desnos  and  Krzwicki  even  go 
so  far  as  to  state  that,  in  their  opinion,  in  most  cases  of  genito- 
urinary tuberculosis  the  prostate  is  the  organ  which  is  first  infected 
with  tubercle  bacilli,  and  from  that  focus  the  infection  subsequently 
travels  to  the  adjacent  structures.  This  point  is  important  to  bear 
in  mind  in  connection  with  the  operative  treatment,  which  will  be 
considered  later. 

The  time  of  life  at  which  tuberculosis  is  most  apt  to  fasten  upon 
the  genital  organs  is  that  period  at  which  sexual  activity  is  most 
highly  developed,  and  consequently  we  find  that  our  patients  are  usu- 
ally between  twenty  and  forty-five  years  of  age. 

Predisposing  causes  play  an  important  role  in  the  etiology  of 
tuberculosis  of  the  prostate.  Anything  which  induces  prolonged  and 
oft-repeated  congestion  of  the  posterior  urethra  weakens  the  resist- 
ance of  the  tissues;  consequently  a  tubercular  outbreak  is  more 
liable  to  occur  in  the  person  of  a  young  man  who  has  practiced  some 
form  of  sexual  abuse  or  has  been  the  subject  of  a  prolonged  attack 
of  gonorrhoea  of  the  posterior  urethra.  But  this  in  itself  is  not  suffi- 
cient to  cause  the  disease,  and  to  bring  this  about  the  tubercle  bacilli 
must  be  actually  introduced  into  and  develop  in  the  substance  of 
the  gland. 

As  to  the  modes  of  infection,  the  micro-organisms  are  most  fre- 
quently brought  to  the  prostate  in  the  blood-circulation,  often  from 
a  tubercular  deposit  in  some  distant  organ.  In  other  cases  they  may 
be  taken  into  the  body  through  the  respiratory  or  alimentary  tracts, 
and,  passing  along  with  the  blood-current,  be  ultimately  deposited  in 

the  prostate. 

18  (221) 


223  DISEASES  OF  THE  PROSTATE. 

The  inoculation  of  bacilli,  however,  may  be  direct,  and  be  occa- 
sioned by  an  infected  catheter  or  through  coitus  with  a  tuberculous 
female,  or  the  prostate  may  be  infected  by  a  process  of  extension 
from  some  neighboring  organ. 

PATHOLOGY. 

A  deposit  of  tubercle  takes  place  in  the  substance  of  the  pros- 
tate, and  either  one  or  both  lobes  are  affected.  The  tubercular 
nodules  are  multiple  from  the  beginning,  or  else  soon  become  so,  and 
they  enlarge  until  several  coalesce,  when  they  break  down  and  form 
abscesses. 

Unless  removed  by  operation,  the  pus  bursts  through  into  the 
rectum  or  urethra  or  even  the  hypogastrium,  and  multiple  fistulous 
tracts  are  formed.  In  rare  instances  the  cheesy  mass  becomes  the 
seat  of  calcareous  changes,  or  the  fluid  portion  of  the  mass  is  absorbed 
and  the  residue  is  encapsulated,  and  a  healing  of  the  lesion  results. 

It  is  important  to  note  that  the  bladder  and  seminal  vesicles 
are  always  involved  sooner  or  later  in  the  course  of  the  disease.  The 
epididymis  is  also  affected,  although  in  many  cases  this  organ  is  the 
first  attacked,  and  the  infection  extends  to  the  prostate  subsequently. 

SYMPTOMS  AND  COURSE. 

If  the  process  begins  in  the  central  part  of  the  prostate,  no 
definite  symptoms  are  caused;  but  if  the  nodules  are  located  super- 
ficially, and  cause  a  bulging  of  the  prostate  toward  the  rectum,  a 
sense  of  weight  in  the  perineum  and  difficulty  in  defecating  is  ex- 
perienced. 

If,  on  the  other  hand,  the  tubercular  foci  lie  close  to  the  urethra, 
the  symptoms  are  those  of  posterior  urethritis,  viz.:  frequent  and 
urgent  urination,  accompanied  by  a  muco-purulent  discharge  from 
the  urethra  and  shreds  in  the  urine. 

There  is  no  distinct  pain  after  the  act  of  micturition,  but  a  feel- 
ing as  though  the  bladder  were  not  fully  emptied. 

Defecation  spermatorrhoea  sometimes  occurs  if  the  deeper-ljdng 
prostatic  tubules  are  infiltrated  with  nodules,  and  another  form  of 
secretion  from  the  meatus  is  occasioned  by  the  breaking  down  and 
discharge  of  small  abscesses  through  the  urethra. 

Haematuria  is  a  frequent  symptom,  and  is  not  constant,  but  in- 
termittent.   The  blood  comes  at  the  end  of  urination,  and  is  not  due 


i 


TUBERCULOSIS  OF  THE  PROSTATE.  223 

to  an  ulceration  of  the  urethra,  as  formerly  supposed,  but  merely 
to  the  congestion  of  the  prostate. 

In  uncomplicated  cases  pain  may  be  excruciating,  and  is  some- 
times so  severe  that  it  overshadows  all  the  other  symptoms. 

As  the  disease  progresses  the  bladder  is  always  affected.  This 
is  announced  by  the  occurrence  of  pain  after  urination  and  tenesmus, 
and  as  the  cystitis  grows  worse  the  bladder  symptoms  become  the 
marked  feature  in  the  case. 

In  most  cases  of  tuberculous  prostatitis  death  is  caused  by  an 
ascending  infection,  involving  first  the  bladder  and  subsequently  the 
kidneys,  or  the  lungs  may  be  attacked,  or  a  general  miliary  tuber- 
culosis may  be  established. 

In  a  few  rare  instances  the  disease  remains  limited  to  the  pros- 
tate; an  abscess  forms,  which  breaks  and  discharges,  the  cavity 
cicatrizes,  and  a  cure  follows. 

DIAGNOSIS. 

On  rectal  examination  the  tubercular  prostate  will  be  found 
enlarged  in  one  or  both  lobes.  The  enlargement  is  distinctly  nodular 
or  lumpy,  and  at  first  of  a  stony  hardness.  After  the  abscess  forms 
points  of  softening  with  fluctuation  can  be  readily  felt. 

It  is  often  extremely  difficult,  indeed  sometimes  impossible,  to 
determine  whether  the  enlargement  is  in  the  prostate  or  involves  the 
seminal  vesicles,  for  these  different  organs  may  be  so  blended  together 
by  the  inflammatory  exudation  that  the  lines  of  demarcation  cannot 
be  defined.  On  this  account  it  was  formerly  supposed  that  every 
tubercular  process  in  this  region  was  confined  to  the  prostate, 
whereas  we  now  know  it  to  be  true  that  the  tubercular  process  may 
attack  prostate  and  vesicles  together,  or  either  organ  be  involved  alone. 

The  gonorrhoeal  inflammations  of  the  prostate,  chronic  pros- 
tatitis, or  the  acute  suppurative  form  resembles  in  physical  signs  the 
tuberculous  disease,  and  it  is  impossible  definitely  to  establish  the 
diagnosis  of  tuberculosis  until  the  presence  of  tubercle  bacilli  has 
been  demonstrated  in  the  secretions.  These  may  be  collected  by 
expressing,  with  the  finger  in  the  rectum,  the  secretions  from  the 
prostate  gland;  and  the  bacilli  are  also  generally  present  in  the  dis- 
charge from  the  meatus  which  so  often  exists. 

If  no  tubercle  bacilli  are  found  in  examining  the  secretions, 
guinea-pigs  may  be  inoculated  with  the  discharges,  and,  if  the  pig 
develops  tuberculosis,  the  diagnosis  is,  of  course,  established. 


224  DISEASES  OF  THE  PROSTATE. 

In  cases  of  general  tuberculosis  it  is  usually  safe  to  consider 
every  enlargement  of  the  prostate  tubercular  in  character,  and  the 
only  difficulty  in  diagnosis  arises  in  the  cases  where  the  prostate  is 
the  seat  of  primary  tuberculosis. 

PROGNOSIS. 

The  prognosis  is,  of  course,  of  the  gravest,  although  when  the 
tuberculosis  is  limited  to  the  prostate  alone  spontaneous  cure  some- 
times occurs  through  healing  of  the  cavity  after  the  abscess  has 
formed  and  burst. 

Unfavorable  elements  in  the  case  are  an  hereditary  predisposi- 
tion to  tuberculosis  and  a  tendency  for  the  disease  to  extend  and 
involve  other  organs. 

TREATMENT. 

The  general  treatment  consists  in  endeavoring  to  vitalize  the 
tissues  by  means  of  a  life  in  the  open  air  or  a  prolonged  sea-voyage, 
abundance  of  nourishing  food,  and  the  administration  of  codliver-oil, 
creasote,  guaiacol,  and  other  antitubercular  remedies. 

There  is  a  difference  of  opinion  as  to  the  advisability  of  begin- 
ning local  treatment  early.  In  general,  it  is  better  to  avoid  instru- 
mentation, for  the  reason  that  the  local  resistance  of  the  tissues  is 
reduced,  and  infection  of  the  bladder  with  other  micro-organisms 
readily  occurs. 

On  the  other  hand,  instillations  into  the  posterior  urethra  in 
the  early  stages  have  their  advocates.  Guyon  advises  sublimate  sol., 
1-5000  to  1-3000;  and  iodoform  in  glycerin  is  warmly  recommended 
by  Berkeley  Hill.  Everyone  is  agreed  that  nitrate  of  silver  uniformly 
acts  badly,  and  its  use  is  contra-indicated. 

After  cystitis  has  set  in  the  principal  indications  are  to  control 
the  pain  and  tenesmus,  but  these  matters  have  been  considered  in 
another  section.     (See  "Cystitis.") 

Under  the  head  of  operative  treatment  may  be  considered,  first, 
the  suggestion  of  Hoffmann,  which  was  to  inject  10-per-cent.  emul- 
sion of  iodoform  and  glycerin  into  the  substance  of  the  prostate  by 
means  of  a  long  needle  thrust  in  through  the  perineum.  This 
procedure  has  never  gained  favor,  and  is  to-day  practically  aban- 
doned. 

A  few  years  ago,  when  the  dictum  of  Sir  Henry  Thompson,  that 
"tuberculosis  of  the  prostate  was  never  primary,  but  always  secondary 


TUBERCULOSIS  OF  THE  PROSTATE.  225 

to  deposits  elsewhere,"  was  accepted  as  final,  it  was  thought  useless 
to  attempt  to  extirpate  the  diseased  prostate,  and  the  rule  was  only 
to  operate  when  pus  had  formed,  in  order  to  evacuate  the  contents  of 
the  abscess. 

At  the  present  time  the  opinion  has  changed,  and  the  operation 
of  laying  bare  the  prostate  by  a  semilunar  incision  curving  around 
the  rectum  and  removing  all  the  diseased  tissue  with  a  curette  com- 
mends itself  as  a  rational  and  conservative  procedure,  and  one  which 
is  likely  to  bring  about  a  radical  cure,  when  the  disease  is  limited  to 
the  prostate  alone. 

^Yhen  the  prostate  is  secondarily  affected,  and  deposits  exist  in 
other  organs,  the  indication  for  operation  is  not  so  clear,  but  even  in 
these  cases  an  operation  is  likely  to  save  the  patient  the  misery  and 
suffering  from  a  prolonged  course  of  suppuration  of  the  prostate, 
with  the  slow  formation  of  fistula. 


DISEASES  OF  THE  KIDNEYS. 


CHAPTER    XVL 

MOVABLE  KIDNEY. 

An  unnatural  movability  of  the  kidney  occurs  in  two  forms: — 

(a)  Movable  kidney  is  more  frequent  in  its  occurrence  than 
the  other  form.  In  this  variety  the  kidney  moves  about  freely  be- 
hind the  peritoneum,  as  it  lies  in  a  sort  of  pouch  or  cavity  formed 
within  its  own  fatty  capsule. 

(b)  True  floating  kidney  lies  closely  surrounded  by  its  fatty 
capsule,  and  is  supplied  with  a  mesonephron,  which  is  attached  by 
one  end  to  the  spinal  column,  but  which  is  so  long  that  it  allows  the 
kidney  to  float  about  freely  in  the  peritoneal  cavity.  The  extent  of 
the  excursions  of  the  kidney  depends  only  upon  the  length  of  its 
mesonephron. 

ETIOLOGY, 

Movable  kidney  occurs  more  frequently  in  females  than  in  males, 
Lindner  finding  that  1  out  of  every  5  or  6  women  examined  were  so 
affected,  and  the  right  kidney  is  more  frequently  movable  than  the 
left. 

True  floating  kidney  is  either  caused  by  a  congenital  meso- 
nephron or  it  may  exceptionally  be  the  last  stage  of  a  movable 
kidney. 

Various  reasons  are  suggested  for  the  preponderance  of  movable 
kidney  in  the  female,  the  chief  of  which  are  laxity  of  the  abdominal 
walls  as  a  result  of  child-bearing.  On  closer  scrutiny,  the  facts  do  not 
uphold  this  theory,  for  a  movable  kidney  is  found  as  often  among 
virgins  and  nulliparse  as  among  women  who  have  borne  children. 

It  is  probable,  however,  that  the  cause  of  movable  kidney  in 
both  sexes  is  the  absorption  of  the  fat  which  surrounds  the  kidney 
and  acts  as  a  cushion  and  support  to  it,  as  a  consequence  of  the 
emaciation  occurring  in  wasting  diseases. 

If  the  fat  is  absorbed,  a  slight  blow  or  muscular  strain,  such 


MOVABLE  KIDNEY.  227 

as  the  exertion  of  vomiting,  may  be  enough  to  loosen  the  kidney  from 
Its  attachment  and  permit  it  to  move  about  more  or  less  freely. 


SYMPTOMS. 

The  symptoms  of  movable  kidney  are,  of  course,  obscure. 
Gastro-intestinal  symptoms,  such  as  flatulence  and  dyspepsia,  are 
generally  present,  and  have  been  accounted  for  by  the  supposition 
that  the  kidney  in  its  abnormal  situation  exerts  pressure  upon  the 
duodenum  and  narrows  its  lumen,  thus  causing  partial  retention  and 
fermentation  of  its  contents. 

Edebohls  considers  these  symptoms  due  to  pressure  and  traction 
upon  or  stretching  and  irritation  of  fibres  of  the  solar  plexus,  lying 
in  the  abdomen  and  belonging  to  the  sympathetic  nervous  system, 
because  it  would  seem  that  the  theory  of  obliteration  of  the  lumen 
of  the  duodenum  is  insufficient  to  account  for  the  symptoms. 

Edebohls  calls  attention  to  the  other  symptoms  which  are  gen- 
erally caused  by  floating  kidney,  as  follows:  Pain  is  felt  in  the  epi- 
gastrium, which  is  not  increased  by  pressure,  and  is  located  some- 
where to  the  left  of  the  median  line  at  or  near  the  free  border  of 
the  left  costal  cartilages.  General  nervousness  in  greater  or  less 
degree  exists,  and  is  usually  accompanied  by  cardiac  palpitation  and 
habitually  rapid  action  of  the  heart. 

These  patients  are  also  unable  to  sleep  or  to  rest  comfortably 
while  lying  upon  the  left  side. 

In  true  floating  kidney  with  a  long  mesonephron  in  addition 
to  the  presence  of  the  abov^-mentioned  disturbances  the  patient 
is  conscious  of  abdominal  pains,  of  a  dragging  or  pulling  character, 
and  the  sensation  is  felt  as  if  some  foreign  body  were  moving  about 
in  the  abdominal  cavity,  particularly  after  a  sudden  muscular  exer- 
tion, or  upon  rising  up  suddenly  after  lying  down. 

The  pain  may  be  only  wearing  in  character  or  it  may  occur  in 
paroxysms  and  be  agonizing.  Its  onset  is  sudden,  and  it  is  apt  to 
follow  fatigue  or  active  exertion.  The  pain  in  some  cases  is  due  to 
attacks  of  local  peritonitis. 

Nervous  disturbances,  hypochondria,  melancholia,  and  hysteria 
usually  occur,  either  as  reflexes  or  from  disturbances  of  nutrition. 
The  secretion  of  urine  by  the  misplaced  kidney  is,  in  general,  not 
interfered  with. 


228  DISEASES  OF  THE  KIDNEYS. 

DIAGNOSIS. 

The  diagnosis  is  not  difficult  to  make  in  thin  subjects  with 
relaxed  abdominal  walls.  By  palpating  the  flank  between  the  fixed 
border  of  the  ribs  and  the  crest  of  the  ilium  the  displaced  kidney 
can  be  felt  between  the  two  hands. 

In  fat  subjects  the  diagnosis  presents  greater  difficulties.  If  the 
kidney  has  been  displaced  into  the  pelvis,  it  may  be  mistaken  for 
an  ovarian  or  fibroid  tumor;  but  the  kidney  may  be  differentiated  by 
replacing  it  with  ease  in  its  natural  position  in  the  flank,  while  the 
attachment  of  its  mesonephron  prevents  its  complete  descent  into 
the  pelvis. 

If  the  mesonephron  is  shorter  and  the  kidney  is  found  lying  in 
the  abdomen,  it  might  be  looked  upon  as  a  distended  gall-bladder, 
enlargement  of  the  spleen,  or  a  tumor  of  the  omentum. 


PROGNOSIS. 

A  kidney  which  once  becomes  movable  never  again  becomes 
firmly  fastened  in  place,  except  by  operative  interference. 

A  misplaced  kidney,  however,  is,  in  general,  not  fatal  to  life, 
and,  if  death  occurs,  it  is  usually  the  result  of  exhaustion  from 
chronic  dyspepsia,  continued  pain,  and  nervous  depression,  although 
death  is  sometimes  due  to  malignant  disease  developing  in  the  dis- 
placed organ. 

TREATMENT. 

The  symptoms  of  movable  kidney  may  be  ameliorated  by  lying  in 
bed,  by  the  Weir  Mitchell  treatment,  and  by  massage  and  electricity; 
but  none  of  these  methods  offer  much  prospect  of  permanent  relief 
(Edebohls). 

A  simple  bandage  of  elastic  webbing  without  any  pad  over  the 
kidney  and  which,  encircling  the  whole  abdomen,  makes  as  much 
pressure  as  the  patient  can  comfortably  bear,  helps  to  support  all  the 
abdominal  viscera  and  with  them  the  kidney.  Such  a  method  may  be 
tried  before  proceeding  to  operation,  but  it  is  generally  found  to  be 
ineffective  in  holding  the  kidney  in  place. 

On  account  of  the  difficulty  of  retaining  the  kidney  in  position, 
nephrorrhaphj^,  or  fixation  of  the  kidney,  is  advised  by  Edebohls  as 
the  first  resort  in  patients  with  movable  kidneys  which  produce  decided 
symptoms. 


RENAL  CALCULUS.  229 

Nephrorrhaphy  is  an  operation  which  is  not  attended  with  much 
danger  to  life  and  it  is  generally  successful  in  fixing  the  kidney  and 
relieving  the  symptoms.  Delvoie  reports  215  cases  operated  on  by  fixa- 
tion, of  which  135  were  cured,  30  improved,  25  unimproved,  20  re- 
lapsed, and  5  died. 

Nephrectomy,  or  total  removal  of  the  kidney,  has  no  justification 
when  the  kidney  has  only  a  small  range  of  motion,  and  the  operation 
is  accompanied  by  a  very  high  mortality. 

In  cases  of  true  floating  kidney  with  a  long  mesonephron  it  may 
be  impossible  to  fix  the  kidney  in  place.  Such  a  contingency  would 
demand  nephrectomy  by  the  lumbar  incision  if  possible,  and,  if  this 
is  not  practicable,  by  means  of  a  laparotomy,  although  the  mortality 
is  much  higher  with  the  abdominal  route  than  when  the  kidney  is 
removed  through  the  flank  and  without  opening  the  peritoneal  cavity. 


RENAL  CALCULUS. 

The  formation  of  stone  in  the  kidneys  is  of  frequent  occurrence, 
and  often  precedes  vesical  calculus.  Stones  composed  of  uric-acid 
crystals  are  most  common,  and  the  next  in  point  of  frequency  are 
oxalic  stones.  Phosphatic  calculi  are  rare,  and  are  caused  by  the  alka- 
line decomposition  of  urine  as  a  result  of  pyogenic  infection. 

The  stones  are  found  in  the  pelvis  of  the  kidney,  and  may  be 
single  or  may  be  in  hundreds. 

ETIOLOGY. 

The  causation  of  kidney  stone  is  generally  the  gouty  diathesis 
(see  "Vesical  Calculus").  A  few  crystals  are  agglomerated  in  one  of 
the  renal  tubules  upon  some  substance,  such  as  a  blood-clot,  coagulura 
of  pus,  or  roughness  of  the  wall,  which  serves  as  a  nucleus.  The  ag- 
glomeration is  washed  out  into  the  pelvis  of  the  kidney,  where  it  be- 
comes the  nucleus  of  a  calculus. 

The  stone,  if  single,  may  be  adherent  to  the  walls  of  the  pelvis 
of  the  kidney,  or  it  may  be  movable  and  act  as  a  ball-valve,  closing  the 
mouth  of  the  ureter.  The  urine  is  dammed  back,  in  consequence  caus- 
ing liydroneplirosis. 


230  DISEASES  OF  THE  laDNEYS. 

Infection  with  micro-organisms  usually  occurs,  and  suppurative 
nephritis  follows. 

SYMPTOMS. 

A  stone  may  be  present  in  the  kidney  for  years  without  causing 
much  discomfort,  as  the  symptoms  are  due,  not  to  the  mere  presence 
of  a  foreign  body,  but  to  obstruction.    They  are  as  follow: — 

(a)  Attacks  of  renal  colic. 

(ft)  Pain. 

(c)  Haematuria. 

(d)  Pyuria. 

(e)  Disturbances  of  urinary  function. 
(/)  G astro-intestinal  disturbances. 

(g)  Passage  of  fragments  of  calculi. 

Attacks  of  renal  colic  are  strongly  indicative  of  kidney  stone, 
although  typical  paroxysms  may  be  induced  by  other  causes,  and  not 
infrequently  renal  stone  has  been  diagnosed  and  operated  for  and  its 
absence  demonstrated  on  cutting  open  the  kidney. 

Eenal  colic  is  caused  by  the  stone  being  forced  out  of  the  pelvis 
of  the  kidney  and  entering  the  ureter.  An  attack  comes  on  abruptly, 
and  is  characterized  by  agonizing  pain,  which  is  felt  in  the  loin,  and 
radiates  down  into  the  testicle  and  along  the  inner  side  of  the  thigh. 

The  pain  may  also  radiate  through  the  abdomen  and  chest,  and 
be  very  intense  in  the  back.  In  severe  attacks  nausea  and  vomiting 
occur,  the  pulse  is  feeble,  the  skin  is  covered  with  a  cold  sweat,  and 
the  patient  is  in  a  state  of  collapse. 

In  lighter  cases  urination  is  frequent,  and  the  urine  discolored 
with  blood,  or  the  patient  may  be  unable  to  empty  his  bladder. 

In  rare  cases  the  secretion  of  urine  may  be  entirely  suppressed 
either  from  (a)  reflex  disturbance  of  the  secreting  kidney;  (b)  exten- 
sive disease  of  the  other  kidney,  whose  ureter  is  not  blocked;  (c)  where 
only  one  kidney  exists  in  the  body. 

In  these  cases  uremic  symptoms  develop  after  a  week,  and  death 
takes  place  within  a  fortnight  after  the  obstruction. 

The  pain  and  disturbance  of  ureteral  colic  may  last  for  a  few 
minutes  or  for  a  number  of  hours,  and  usually  ceases  abruptly  as  the 
stone  either  drops  back  into  the  pelvis  of  the  kidney  or  makes  its  escape 
from  the  lower  end  of  the  ureter  and  enters  the  bladder. 

The  stone  occasionally  becomes  permanently  fixed  in  the  ureter, 
in  which  case,  after  some  time,  the  walls  give  way  slightly  around  it, 


RENAL  CALCULUS. 


231 


permitting  a  portion  of  the  urine  to  pass  by;  but  the  urine  is  dammed 
back  upon  the  kidney,  and  hydronephrosis  is  developed. 

Pain  is  felt  over  the  affected  kidney,  which  is  increased  by  motion, 
jarring,  and  pressure  over  the  side. 

The  sensation  is  that  of  a  feeling  of  vi'eight,  rather  than  of  acute 
pain,  but  the  patient  is  liable  to  have  paroxysms  of  acute  pain,  which 
often  occur  at  night,  when  he  is  at  rest  in  bed. 

The  pain  radiates  along  the  ureter  and  into  the  testicle,  and  often 
causes  contraction  of  the  cremaster  muscle,  with  drawing  up  of  the 
testicle  on  the  affected  side.  The  pain  may  be  referred  to  the  healthy 
kidney  or  to  the  bladder,  thigh,  or  calf  of  the  leg. 

Hsematuria  occurs  most  frequently  when  the  stone  is  passing 
through  the  ureter,  but  may  appear  when  the  stone  is  in  the  pelvis  of 
the  kidney. 

The  bleeding  may  come  on  in  a  slight  amount,  giving  the  urine 
a  smoky  color,  or  the  urine  may  be  free  for  days  until,  after  some 
sudden  exertion  or  a  prolonged  ride,  a  considerable  amount  of  bleeding 
takes  place. 

Pyuria  occurs  only  after  suppurative  disease  of  the  kidney  has 
occurred,  but  this  is  usually  established  in  time. 

Disturbances  of  Urinaxy  Function. — The  irritative  effect  of  stone 
in  the  kidney  causes  it  to  secrete  an  excessive  quantity  of  urine  by  day 
when  the  patient  is  moving  about,  but  at  night,  when  he  is  quiet  in 
bed,  the  secretion  of  urine  is  normal  in  quantity. 

As  a  result  of  blocking  the  ureter  with  a  stone,  the  urine  may  be 
diminished  in  quantity  or  entirely  suppressed  for  a  time.  If  it  per- 
sists after  the  attack  is  past,  it  is  clear  either  that  the  ureter  of  the 
functionating  kidney  is  blocked  with  a  stone  and  that  the  other  kidney 
is  so  much  diseased  that  it  is  not  capable  of  secreting  or  else  that  there 
is  only  one  kidney  present. 

Occasionally  the  obstruction  develops  insidiously  without  attract- 
ing attention  until  symptoms  of  uraemia  set  in. 

Gastro-intestinal  disturbances  may  be  reflex  in  origin  or  may 
result  from  imperfect  elimination  by  the  diseased  kidneys.  Dyspepsia, 
vomiting,  and  epigastric  tenderness  may  easily  cause  the  condition  of 
the  kidneys  to  be  overlooked. 

Passage  of  fragments  of  calculi  is  very  often  absent,  or  the  frag- 
ments are  overlooked  by  the  patient,  but  when  present  it  is  of  great 
value  in  indicating  the  presence  of  kidney  stone,  even  though  colic  was 
not  caused  by  the  passage  of  the  fragments  through  the  ureters. 


233  DISEASES  OF  THE  KIDNEYS. 

DIAGNOSIS. 

A  positive  diagnosis  of  renal  calculus  is  difficult  to  make,  and 
many  cases  are  on  record  in  which  the  kidney  was  incised  for  the  pur- 
pose of  removing  a  stone  when  none  was  present. 

The  most  characteristic  symptoms  of  kidney  stone  are  passage  of 
gravel  or  fragments  of  stone,  attacks  of  typical  renal  colic,  h?ematuria, 
and,  in  time,  pyelitis. 

Hasmaturia  and  pain  are  often  caused  by  tubercular  or  malignant 
disease  of  the  kidney,  and  oxaluria  and  strongly-acid  urine  occasion  a 
dull  ache  over  the  kidneys  or  even  paroxysms  of  pain,  which  are  some- 
times accompanied  by  hematuria. 

Spinal  caries  of  the  lower  dorsal  vertebrae  and  locomotor  ataxia 
may  simulate  the  pain  of  kidney  stone. 

During  an  attack  of  renal  colic  it  may  be  impossible  to  distinguish 
between  the  passage  of  a  gall-stone  or  of  a  stone  through  the  ureter. 

Before  attempting  any  operation  it  is,  of  course,  essential  to  de- 
termine if  both  kidneys  are  affected  or  if  the  disease  is  confined  to  one 
side  only.  The  location  of  the  pain  and  tenderness  on  palpation  throw 
some  light  as  to  which  side  the  disease  is  located  upon;  but  the  ques- 
tion may  be  settled  positively  by  catheterization  of  the  ureters. 

The  x-ray  has  been  of  great  use  since  its  introduction  in  diag- 
nosing cases  of  kidney  stone,  and  is  now  regarded  as  one  of  the  indis- 
pensable diagnostic  aids. 

As  a  final  resort  in  the  cases  where  stone  is  suspected  and  the 
patient's  health  is  failing,  it  is  justifiable  to  make  an  exploratory  in- 
cision into  the  kidney  by  lumbar  nephrotomy. 


PROGNOSIS. 

A  stone  may  remain  in  the  pelvis  of  the  kidney  for  years  without 
causing  any  serious  disability,  and  only  at  times  inducing  transient 
pain  or  hsematuria;  but  the  patient  is  continually  exposed  to  the 
danger  of  obstruction  of  the  ureter  and  suppuration  of  the  kidneys 
from  pyogenic  infection. 

If  a  fragment  of  stone  passes  into  the  ureter,  it  usually  escapes 
into  the  bladder,  but  if  it  become  impacted  in  the  ureter,  disorganiza- 
tion of  the  kidney  ultimately  takes  place,  and  the  same  is  true  if  sup- 
puration of  the  kidney  occurs. 


RENAL  CALCULUS.  233 

TREATMENT. 

Attcacks  of  renal  colic  are  sometimes  cut  short  by  a  prolonged  hot 
bath  and  a  full  dose  of  morphia  hypodermically. 

In  giving  opium  it  is  necessary  to  exercise  caution  and  not  give 
too  large  a  quantity,  for  as  soon  as  the  stone  is  released  and  slips  out 
of  the  ureter  the  pain  ceases,  and  the  patient  may  be  overcome  by  the 
effect  of  the  drug. 

In  cases  which  do  not  respond  to  morphia  it  may  be  necessary  to 
secure  relaxation  by  means  of  anaesthesia  with  chloroform  or  ether. 

In  the  intervals  of  the  attacks  the  general  diathetic  condition  of 
the  patient  upon  which  the  formation  of  stone  depends  should  receive 
proper  attention  (see  "Treatment  of  Stone  in  the  Bladder"). 

But  little  success  has  been  attained  by  efforts  at  dissolving  stones. 
Piperazin  in  5-grain  doses  taken  in  a  pint  of  water  three  times  a  day 
is  thought  to  have  some  effect  in  dissolving  the  albuminous  frame- 
work of  a  uric-acid  calculus,  and  phosphatic  stones  may  perhaps  be 
softened  and  broken  down  by  Urotropin. 

The  most  important  point  in  the  treatment,  in  addition  to  regu- 
lation of  the  diet  and  general  hygiene,  is  to  keep  the  urine  abundant 
and  of  low  specific  gravity  by  drinking  freely  of  pure  spring-  or  dis- 
tilled water. 

Although  a  stone  may  remain  for  years  in  the  pelvis  of  the  kidney 
without  danger  to  life,  certain  conditions — such  as  a  deterioration  of 
the  general  health,  blocking  of  the  ureter,  or  pyogenic  infection  of  tbe 
kidney — call  at  once  for  the  operation  of  nephrolithotomy. 

This  is  indicated  when  the  pain  is  persistent  and  severe,  calling 
for  the  constant  use  of  anodynes  and  accompanied  by  frequent  attacks 
of  renal  colic  and  gradual  emaciation  and  loss  of  strength. 

Through  a  lumbar  incision  the  kidney  can  be  exposed  and  cut 
into,  on  its'  outer  convex  side,  sufficiently  to  admit  the  finger  into  its 
pelvis,  which  can  be  thoroughly  searched  and, the  stone  found  and 
removed. 

If  the  kidney  has  been  the  seat  of  prolonged  suppuration  and  has 
undergone  complete  disorganization,  nephrectomy  (entire  removal  of 
the  kidney)  may  be  indicated. 


234 


DISEASES  OF  THE  IvIDNEYS. 


PYELITIS. 

In  suppurative  pyelitis,  often  called  surgical  kidney,  the  pelvis  of 
one  kidne}'  may  be  attacked  alone  or  both  Iddneys  may  be  affected. 

The  pathological  change,  if  due  to  an  ascending  infection,  begins 
in  the  pelvis  of  the  kidney,  which  becomes  distended  with  pus,  and  if 
the  ureter  is  blocked  so  that  the  pus  cannot  be  discharged  into  the 
bladder,  in  course  of  time  the  interstitial  secreting  substance  of  the 
kidney  is  utterly  destroyed  and  the  organ  is  converted  into  a  mere 
shell  surrounded  by  its  capsule  and  filled  with  pus.  This  condition  is 
called  pyonephrosis. 

In  pyelonephritis  the  suppurative  process  involves  not  only  the 
pelvis,  but  the  secreting  structures  of  the  kidney  as  well. 

A  number  of  small  abscesses  form  between  the  tubules,  and  as 
they  increase  in  size  the  intervening  portions  of  tissue  break  down,  so 
that  several  of  the  abscesses  become  merged  into  one. 

The  secreting  parts  of  the  kidney  involved  in  the  process  are  de- 
stroyed and  the  secretory  function  of  the  kidney  is,  of  course,  im- 
paired. 

After  destruction  of  the  kidney-substance  the  fluid  portion  of  the 


Fig.  73. — Tuberculous  Pyelonephritis. 


PYELITIS.  235 


pus  is  often  absor'bed,  and  upon  autopsy  the  kidney  is  found  to  be 
made  up  of  several  saeculi  containing  grayish,  putty-like  masses,  whidi 
are  often  mixed  with  calcareous  material. 


ETIOLOGY. 

Suppuration  of  the  kidney  is  always  caused  by  micro-organisms, 
of  which  the  most  frequent  forms  are  the  staphylococcus  aureus  and 
the  colon  bacillus,  and  in  tubercular  pyelitis  the  tubercle  bacillus. 

The  modes  of  infecticn  may  be  (a)  ascending,  caused  by  the  pas- 
sage of  micro-organisms  from  the  bladder  upward  through  the  ureters, 
and  (b)  hematogenous,  in  which  case  infective  emboli  occurring  in  sep- 
sis, tuberculosis,  or  the  infectious  fevers  are  conveyed  to  the  kidney 
through  the  blood-current. 

Predisposing  Causes. — The  most  important  and  frequent  cause  of 
pyelitis  is  inveterate  cystitis  from  the  retention  of  urine  in  the  bladder 
behind  a  stricture  or  enlarged  prostate. 

The  urine  is  dammed  back  upon  the  kidneys,  causing  a  distension 
of  the  pelvis,  and  infection  with  micro-organisms  which  are  conveyed 
through  the  ureters  from  the  bladder  readily  takes  place. 

Eenal  calculi  in  themselves  do  not  excite  pyelitis,  but  the  pro- 
longed mechanical  irritation  to  the  kidney  which  their  presence  causes 
lowers  its  resisting-power  and  permits  the  entry  of  germs. 

Infectious  diseases — such  as  typhoid  fever,  pneumonia,  scarlatina, 
small-pox,  and  general  tuberculosis — lead  to  the  formation  of  infec- 
tious emboli,  which  are  carried  through  the  general  blood-circulation 
and  are  often  deposited  in  the  kidney. 


SYMPTOMS. 

As  most  cases  of  pyelitis  are  secondary  to  some  other  condition, 
the  symptoms  are  obscured  by  those  of  the  primary  disease. 

There  are,  however,  certain  definite  symptoms  which  always  ac- 
company pyelitis: — 

(a)  Changes  in  the  Urine. — Pus  is  always  present  in  considerable 
quantities,  although  it  often  disappears  for  a  few  hours,  from  a  tem- 
porary blocking  of  the  ureter. 

Blood  is  frequently  present,  and  is  increased  by  activity  on  the 
part  of  the  patient.  It  may  be  uniformly  disseminated  through  the 
urine  or  appear  as  long  clots  formed  in  the  ureters. 


236  DISEASES  OF  THE  KIDNEYS. 

The  quantity  of  urine  secreted  is  increased,  and  is  from  two  to 
three  times  the  normal  amount.  Its  reaction  is  persistently  acid,  un- 
less cystitis  is  established,  when  it  becomes  ammoniacal,  and  the  symp- 
toms of  C3'stitis — pain,  tenesmus,  and  frequent  urination — occur. 

Microscopic  examination  of  the  sediment  shows  pus,  albumin, 
small  quantities  of  epithelial  cells  from  the  pelvis  of  the  kidney,  con- 
siderable mucin,  and  numberless  micro-organisms. 

If  pyelitis  is  dependent  upon  a  renal  calculus,  in  addition  to 
the  pus-cells  fragments  of  the  calculus  may  be  present,  and  crystals 
of  uric  acid,  urates,  or  triple  phosphates  are  always  found.  The 
quantity  of  desquamated  epithelium  is  greater,  and  some  blood  is 
present. 

(l)  Fever  of  an  intermittent  type  often  accompanied  by  chills, 
which  may  be  easily  mistaken  for  malaria,  is  a  prominent  symptom. 

(c)  Emaciation  and  progressive  deterioration  of  health  are  re- 
sults of  the  fever  and  toxsemia.  In  old  men  the  appetite  and  strength 
fail,  the  tongue  becomes  dry  and  brown,  and  the  pulse  feeble  and 
intermittent. 

(d)  Pain  is  rarely  a  prominent  symptom,  unless  caused  by  a  kid- 
ney calculus,  although  a  dull  aching,  which  is  subject  to  exacerba- 
tions, is  experienced. 

It  is  by  no  means  infrequent  that  the  pyelitis  remains  latent 
without  causing  any  symptoms,  until  the  operation  of  litholapaxy, 
internal  urethrotomy,  or  the  commencement  of  catheter-life  causes 
it  to  become  active. 

In  these  cases  the  symptoms  which  arise  are  partly  due  to  want 
of  elimination,  on  account  of  the  destruction  of  the  secreting  portion 
of  the  kidney,  and  partially  from  urinar}'^  fever,  caused  by  the  absorp- 
tion of  micro-organisms  and  toxins  into  the  circulation  from  a  wound 
in  the  genito-urinary  tract. 

The  symptoms  consist  in  a  diminution  in  quantity  or  complete 
suppression  of  urine.  The  urine  contains  blood,  often  in  abundance. 
The  temperature  rises,  and  is  accompanied  by  feeble  pulse  and  great 
prostration.    Delirium  and  coma  set  in,  and  are  followed  by  death. 

DIAGNOSIS. 

The  chief  difficulty  in  making  a  diagnosis  of  pyelitis  is  to  dis- 
tinguish it  from  cystitis. 

To  this  end  pain  and  tenderness  over  the  kidney  and  perhaps 
a  distinct  tumor  may  be  noted  on  palpation. 


PYELITIS. 


237 


The  acidity  of  the  urine,  which  persists  several  days  after  it  is 
passed,  and  the  sudden  fluctuations  in  the  quantity  of  pus  are  si*^- 
nificant  of  pyelitis. 

A  manoeuvre  which  is  sometimes  of  use,  in  differentiating  be- 
tween cystitis  and  pyelitis,  consists  in  washing  out  the  bladder  thor- 
oughly, and  then  waiting  for  fifteen  minutes;  the  urine  which  has 
accumulated  in  the  bladder  during  that  time  is  then  drawn  off  with 
a  catheter. 

If  the  kidneys  are  healthy,  but  cystitis  is  present,  a  small  amount 
of  pus  will  appear  in  the  urine  when  it  is  drawn  off,  but  if  the  bladder 
is  healthy  and  pyelitis  exists,  the  urine  will  contain  a  comparatively 
large  quantity  of  pus. 


Fig.  74. — Nitze's  Cystoscope  for  Catheterizing  the  Ureters. 

The  cystoscope  is  an  important  diagnostic  aid,  and  by  its  use 
cystitis  can  be  excluded  and  the  discharge  of  purulent  urine  can  often 
be  seen  coming  in  jets  from  one  or  both  ureters. 

By  means  of  the  catheterizing  cystoscope  the  ureters  may  be 
catheterized  and  the  urine  from  each  kidney  collected  separately,  or 
Harris's  segregator  can  be  used  for  the  same  purpose.  In  women 
the  Kelly  method  of  catheterizing  the  ureters  can  be  employed. 


PROGNOSIS. 

The  prognosis  of  pyelitis  depends,  of  course,  upon  its  cause. 
When  it  occurs  in  the  course  of  an.  infectious  fever,  recovery  gener- 
ally takes  place.  Tubercular  or  suppurative  pyelitis  may  terminate 
by  inspissation  of  the  pns,  or  it  may  break  through  the  capsule  of  the 
kidney  and  set  up  perinephric  abscess,  or  make  its  way  through  the 
skin  of  the  loin,  or  break  into  the  intestine  or  lungs. 

Double  pyelitis  caused  by  stricture,  calculus,  or  enlarged  pros- 
tate, with  ascending  infection  from  cystitis,  is  generally  fatal,  while 
the  outlook  is  much  better  in  the  case  where  a  single  kidney  is  the 
seat  of  disease,  as  then  operative  interference  is  practicable. 


238  DISEASES  OF  THE  KIDNEYS. 

TREATMENT, 
In  mild  cases  of  pyelitis  occurring  in  the  course  of  an  infectious 
disease  the  patient  should  be  kept  in  bed,  put  on  a  milk  diet,  and 
large  quantities  of  distilled  water  given  by  the  mouth.  Urinary  anti- 
septics— Urotropin  and  salol — are  indicated  and  citrate  of  potash 
should  be  administered  to  diminish  the  acidity  of  the  urine  as  it 
lies  in  the  pelvis  of  the  kidney. 

The  surgical  treatment  includes  the  removal  of  any  obstruction 
to  the  free  escape  of  urine  from  the  bladder,  relief  of  the  cystitis, 
the  removal  of  renal  calculi,  and  the  evacuation  of  collections  of  pus 
in  the  kidney,  nephrotomy  and  under  certain  conditions  nephrectomy, 
or  the  removal  of  the  kidney  itself. 

In  pyelitis  of  gonorrhoea!  origin  and  in  all  acute  cases  which 
after  a  short  time  begin  to  show  improvement,  Caspar  and  Kelly 
suggest  catheterization  of  the  ureters  and  washing  out  the  pelvis  of 
the  kidney  with  3-per-cent.  boric-acid  or  1-  to  3-per-cent.  nitrate-of- 
silver  solutions. 

The  indications  for  surgical  operation  are  intermittent  pyuria 
with  fever  during  the  intermissions  and  septicsemia,  even  though 
the  pus  constantly  escapes  through  the  ureter. 

The  operation  indicated  depends  upon  the  extent  of  the  de- 
structive process  in  the  kidney  and  whether  one  or  both  kidneys  are 
■affected. 

I.  One  Kidney  Alone  Diseased. — (a)  In  the  case  of  an  abscess 
•of  the  kidney,  from  a  punctured  wound  or  a  renal  calculus,  it  is 
•desirable  to  drain  as  early  as  possible,  in  order  to  prevent  destruction 
of  the  kidney-structures. 

(6)  If  the  entire  kidney  is  infiltrated  and  riddled  with  abscesses, 
nephrotomy  is  first  performed  and  the  pus  evacuated.  It  often  hap- 
pens that  the  patient's  condition  improves  and  the  sinus  heals  up 
and  the  remains  of  the  kidney  can  be  left  in  place  to  be  of  some 
degree  of  service  as  an  eliminative  organ.  In  many  cases,  however, 
the  kidney-structure  has  undergone  so  much  disorganization  that 
its  extirpation  is  indicated,  and,  after  the  pus  has  been  evacuated 
by  an  incision,  the  kidney  may  be  removed  a  few  days  later  by 
nephrectomy. 

It  is,  in  all  cases,  considered  safer  to  allow  an  interval  of  a  few 
days  to  elapse  before  removing  the  kidney  entirely,  except  in  cases 
of  tubercular  pyelitis,  where  the  kidney  should  be  entirely  removed 
at  the  primary  operation. 


HYDRONEPHROSIS. 


239 


II.  Both  Kidneys  Diseased. — In  such  conditions  nephrectomy  is 
out  of  the  question,  and  in  feeble  old  men,  who  are  suffering  from 
stricture  or  enlarged  prostate,  no  operation  can  be  undertaken  which 
holds  out  much  prospect  of  recovery. 

If  the  patient  is  in  better  general  condition,  evacuation  of  the 
pus  by  incision  (double  nephrotomy)  may  relieve  the  septic  condition, 
and,  if  the  kidneys  are  not  too  much  disorganized,  they  may  be  able 
to  carry  on  their  eliminative  function  sufficiently  to  maintain  life. 


HYDRONEPHROSIS. 

When,  from  some  mechanical  obstacle  in  the  ureter,  the  urine 
is  prevented  from  flowing  out  from  the  pelvis  of  the  kidney,  reten- 
tion of  the  non-purulent  urine  occurs,  and  the  pelvis  and  calyces 


Fig.  75.— Hydronepluotic  Kidney  without  much  enlargement. 

of  the  kidney  become  enormously  dilated.  Atrophy  of  its  secreting 
substance  takes  place,  with  the  formation  of  distinct  cysts,  which 
may  attain  to  a  very  great  size. 


240  DISEASES  OF  THE  KIDXEYS. 

ETIOLOGY. 

Congenital  Causes. — The  ureter  may  be  entirely  absent,  or  oblit- 
erated in  some  part,  or  the  obstruction  may  develop  after  birth,  on 
account  of  a  twisting  of  the  ureter  or  the  formation  of  a  valve-like 
fold,  causing  partial  or  complete  closure  of  its  lumen. 

If  an  abnormal  insertion  of  the  ureter  exists  either  at  its  origin 
from  the  pelvis  of  the  kidney  or  at  its  entrance  into  the  bladder,  the 
angle  of  the  insertion  of  the  ureter  may  be  so  acute  that  it  is  com- 
pressed and  its  lumen  closed  when  the  patient  is  in  the  standing 
position. 

Acquired  causes  operate  either  by  compressing  the  ureter  or 
obstructing  the  outflow  of  urine  and  causing  it  to  be  dammed  back 
upon  the  kidneys.  Tumors  of  the  ovary  and  uterus,  prostatic  hyper- 
trophy, and  atony  of  the  bladder  will  produce  this  effect  at  times. 

A  very  frequent  cause  of  hydronephrosis  is  a  renal  calculus, 
acting  as  a  ball-valve,  as  it  lies  in  the  pelvis  of  the  kidney  at  the 
mouth  of  the  ureter,  or  if  it  enters  the  ureter  and  becomes  fixed  at 
any  point  in  its  course. 

From  any  of  these  causes  the  obstruction  may  be  complete,  so 
that  no  urine  can  pass  through  the  ureter;  or  it  may  be  incomplete, 
and  a  portion  of  the  urine  passes  through  into  the  bladder. 

Intermittent  hydronephrosis  occurs  chiefly  as  a  result  of  a  mov- 
able kidney,  as  changes  in  the  position  of  the  kidney  cause  bends 
and  twists  in  the  ureter,  and  in  consequence  stagnation  of  the  urine 
in  the  pelvis  of  the  kidney,  and  ultimately  dilatation  with  cystic 
formation. 

The  sac  becomes  completely  filled,  and  then,  if  the  obstruction 
is  temporarily  removed,  it  is  emptied,  and  a  large  discharge  of  urine 
occurs  into  the  bladder,  and  the  hydronephrotic  tumor  disappears. 

The  obstruction  in  the  ureter  returns  and  the  sac  gradually 
refills,  and  after  a  varying  time  is  again  emptied. 

The  process  of  accumulation  and  discharge  is  repeated  indefi- 
nitely unless  the  ureter  becomes  completely  and  permanently  blocked, 
which  usually  occurs  in  the  course  of  time. 


SYMPTOMS. 

The  symptoms  of  hydronephrosis  are  vague  and  indefinite,  and 
consist  in  the  formation  of  a  fluctuating  tumor  in  the  flank,  which 


HYDRONEPHROSIS.  '  241 

may  be  large  enough  to  fill  the  entire  abdominal  cavity,  together  with 
frequent  urination,  and  a  diminution  in  the  quantity  of  urine  passed. 

The  symptoms  caused  by  intermittent  hydronephrosis  are  gener- 
ally occasioned  by  a  movable  kidney,  in  which  condition  the  ureter 
is  obstructed  by  being  bent  at  an  angle. 

The  attacks  are  accompanied  by  violent  pain  and  diminution  in 
the  quantity  of  urine  and  may  easily  be  mistaken  for  an  attack  of 
renal  calculus.  When  the  kidney  falls  back  into  its  normal  place  the 
ureter  is  straightened  out,  the  pain  ceases  suddenly,  and  large  quan- 
tities of  urine  are  discharged. 


PROGNOSIS. 

Hydronephrosis  may  remain  stationary  for  years,  but  the  press- 
ure of  the  accumulated  fluid  leads,  in  time,  to  an  atrophy  of  more 
or  less  of  the  parenchyma  of  the  kidney-substance,  although  the 
secreting  structures  are  never  entirely  destroyed. 

The  affection  is  often  complicated  by  infection  with  pyogenic 
organisms,  and  the  case  becomes  converted  into  one  of  pyelitis,  with 
its  attendant  dangers. 

Large  sacs  have  been  known  to  rupture  into  the  abdominal 
cavity  and  cause  peritonitis,  and,  in  a  few  cases  of  intermittent 
hydronephrosis,  spontaneous  cure  has  occurred. 


DIAGNOSIS. 

The  diagnosis  presents  many  difficulties,  although  a  history  of 
the  sudden  disappearance  of  a  tumor  coincident  with  the  discharge 
of  large  quantities  of  urine  is  eminently  suggestive  of  intermittent 
hydronephrosis. 

All  ovarian  tumor  is  very  liable  to  be  mistaken  for  hydrone- 
phrosis. The  distinguishing  points  are  the  situation  of  the  kidney 
tumor  in  the  flank,  with  the  colon  or  small  intestine  in  front  of  it. 

Exploratory  puncture  of  the  tumor  may  throw  some  light  upon 
the  case,  by  furnishing  a  fluid  containing  urea  or  uric  acid,  but  those 
ingredients  of  urine  often  disappear  by  absorption,  and  the  liquid 
resembles  that  contained  in  any  simple  cyst.  Catheterization  of  the 
ureters  may  settle  the  question  of  diagnosis  by  demonstrating  if 
urine  issues  from  one  or  both  ureters  and  if  it  is  clear  or  purulent. 


242  DISEASES  OF  THE  KIDNEYS. 

TREATMENT. 

It  is  seldom  possible  to  remove  the  obstruction  in  the  ureter 
and  re-establish  the  flow  of  urine  through  it,  except  when  due  to 
movable  kidney  or  pressure  upon  the  ureter  from  an  abdominal 
growth,  and  the  various  attempts  to  do  away  with  the  obstruction 
by  massage  and  ureteral  catheterization,  etc.,  have  been  rarely 
crowned  with  success. 

In  double  hydronephrosis  incision  of  both  saccular  kidneys  by 
lumbar  nephrotomy,  with  an  interval  between  the  two  operations, 
and  the  establishment  of  a  permanent  fistula,  although  causing  great 
inconvenience  to  the  patient,  affords  the  only  hope  of  arresting  the 
destruction  of  the  secreting  portions  of  the  kidney  and  saving  the 
life  of  the  patient. 

In  unilateral  hydronephrosis  incision  and  drainage  through  the 
loin  (nephrotomy)  is  the  operation  of  choice,  and  later  on,  if  the  an- 
noyance of  the  fistula  becomes  unbearable  and  the  other  kidney  is 
found  to  be  healthy,  nephrectomy  may  be  done  upon  the  diseased 
kidney  and  the  fistula  allowed  to  close. 

Before  nephrectomy  is  undertaken  it  may  be  desirable  to  en- 
deavor to  remove  the  obstruction  in  the  ureter  by  catheterization, 
or  the  advisability  of  transplantation  of  the  ureters  may  be  con- 
sidered. 

The  operation  of  aspiration,  or  lumbar  puncture,  although 
formerly  practiced,  is  seldom  employed  to-day,  except  in  the  cases 
where  an  operation  is  strongly  indicated,  but  for  some  reason 
nephrotomy  cannot  be  performed  at  the  time. 

In  certain  cases  of  intermittent  hydronephrosis  a  permanent 
cure  is  said  to  have  followed  the  operation  of  lumbar  puncture. 

"When  hydronephrosis  depends  upon  a  movable  or  floating  kid- 
ney, nephrorrhaphy  is  indicated,  and,  when  the  kidney  is  fixed  in 
place,  the  accumulation  of  urine  and  overdistension  of  the  pelvis 
of  the  kidney  may  cease. 


DISEASES  OF  THE  TESTICLES. 


CHAPTER   XVIL 


ECTOPY  OF  THE  TESTICLE. 


The  testicles  are  developed  in  the  abdominal  cavity  of  the  foetus. 
About  the  fifth  month  of  foetal  life  they  begin  to  descend,  and  pass 
through  the  inguinal  canal  into  the  scrotum,  arriving  there  about  a 


a  ~~ 


Fig.  76.— Testicle  and  Epididymis  Exposed  by  Cutting  away  Part 
of  the  Tunica  Vaginalis. 


A,  Testis. 

B,  Epididymis. 

C,  Tunica  Vaginalis. 


D,  Vas  Deferens. 

E,  Spermatic  Artery  and  Veins. 

F,  Artery  of  Cord. 

(243) 


244  DISEASES  OF  THE  TESTICLES. 

month  before  birth.     One  or  both  testicles  may  fail  to  follow  the 
normal  course,  and  may  be  retained: — 

(a)  In  the  abdomen  (cryptorchism). 

(b)  In  the  inguinal  canal. 

(c)  The  testis  may  take  an  aberrant  course  and  be  found  lodged 
under  the  skin  of  the  abdominal  wall,  the  thigh,  or  perineum. 

ETIOLOGY. 

The  causes  which  operate  to  prevent  the  normal  descent  of  the 
testes  are  obscure.  It  may  be  accounted  for,  however,  by  assuming 
that  the  external  inguinal  ring  is  of  too  small  a  size  to  allow  the 
testicle  to  pass  through  it,  or  that  the  vessels  accompanying  the  sper- 
matic cord  are  too  short  to  allow  the  cord  itself  to  be  stretched 
sufficiently  to  allow  the  testis  to  reach  the  bottom  of  the  scrotum. 
If  the  testicle  is  held  by  a  long  mesorchium  in  the  abdominal  cavity 
its  mobility  may  be  so  great  that  it  slips  past  the  opening  of  the 
inguinal  canal  without  entering  it. 

The  wearing  of  a  truss,  on  account  of  a  hernia,  in  a  case  where 
the  descent  of  the  testicle  has  been  delayed  after  birth,  will  also 
prevent  the  testis  from  arriving  at  its  normal  place  in  the  scrotum. 

Tfie  causes  of  cruro-femoral  and  perineal  ectopy  are  still  more 
obscure.  It  is  thought,  however,  that  an  overdevelopment  of  certain 
bands  of  the  gubernaculum  will  have  the  effect  of  drawing  the  testis 
to  one  side  and  thus  occasioning  its  aberrant  course. 

RESULTS. 

The  results  of  ectopy  are  impairment  of  the  growth  and  de- 
velopment of  the  testis,  so  that  it  remains  undersized,  but  probably 
possesses  the  power  of  forming  spermatozoa,  unless  its  structure  is 
destroyed  by  attacks  of  inflammation,  which  are  very  liable  to  occur. 
After  the  testicle  has  been  disorganized  sterility,  of  course,  follows. 

COMPLICATIONS. 

Hernia  is  a  very  frequent  accompaniment,  and  if  the  testicle  lies 
in  the  inguinal  canal  it  interferes  with  the  wearing  of  a  truss,  so  that 
strangulation  of  the  hernia  is  very  liable  to  occur. 

The  testicle  when  not  lying  protected  by  the  thighs,  in  the 
scrotum,  is  very  liable  to  be  struck  and  bruised,  and  the  ectopic  tes- 
ticle rarely  escapes  several  attacks  of  traumatic  inflammation. 


ECTOPY  OF  THE  TESTICLE.  24^ 

It  is  also  subject  to  gonorrhoeal  inflammation  from  extension 
of  a  gonorrhoea  from  the  posterior  urethra. 

Malignant  disease  is  very  apt  to  occur  in  the  ectopic  testicle, 
and  is  predisposed  to  by  the  attacks  of  inflammation  to  which  the 
testicle  in  this  situation  is  so  liable. 

DIAGNOSIS. 

The  diagnosis  is  made  by  (a)  the  absence  of  the  testicle  from 
the  scrotum;  (&)  the  detection  of  a  smooth,  oval,  soft  tumor  in  the 
inguinal  canal,  which  moves  up  and  down  when  the  patient  coughs 
and  strains. 

The  testicle  should  not  be  mistaken  for  a  hernia,  wbich  often 
complicates  this  condition. 

TREATMENT. 

In  intra-abdominal  ectopy,  or  cryptorchism,  it  is  impossible  to 
rectify  the  condition  by  operation,  as  the  spermatic  cord  is  too  short 
to  admit  of  placing  the  testis  in  the  scrotum. 

In  addition,  as  the  testicle  is  protected  from  traumatism,  in- 
flammation does  not  occur  in  it,  and  the  dangers  of  destruction  of  its 
function,  with  consequent  sterility  or  malignanfdegeneration,  do  not 
occur,  and  the  chief  reasons  for  operation  do  not  exist. 

In  inguinal  retention  it  is  often  possible  by  means  of  gentle 
manipulation  to  push  the  testicle  into  its  proper  place  in  the  scro- 
tum, and  it  may  be  retained  in  position  by  wearing  a  proper  truss, 
which  closes  the  ring  and  prevents  its  return. 

If  this  procedure  fail  to  retain  the  testicle  in  place,  and  the  child 
is  over  six  years  of  age,  a  surgical  operation  should  be  performed,  for 
the  reason  that  the  testicle  does  not  reach  its  full  size  and  functional 
development  while  in  an  abnormal  situation.  From  its  exposed  loca- 
tion it  is  also  constantly  liable  to  blows  and  injuries.  These  lead  to 
repeated  attacks  of  inflammation,  causing  sterility,  and  also  predispose 
to  malignant  disease.  The  selection  of  the  operation  will  depend  upon 
the  history  of  the  case.  An  operation  to  replace  the  testicle  in  the 
scrotum  is  only  advisable  before  the  occurrence  of  attacks  of  inflam- 
mation. After  attacks  of  inflammation  have  occurred,  the  secreting 
structure  of  the  testicle  is  destroyed,  and  the  organ  is  rendered  useless 
and  only  liable  to  disease.  On  this  account  castration  is  indicated,  and 
at  the  same  time  the  inguinal  canal  may  be  examined,  and.  if  hernia 
is  also  present,  it  may  be  radically  cured  and  the  canal  closed. 


246  DISEASES  OF  THE  TESTICLES. 


MALIGNANT  DISEASE  OF  THE  TESTICLE. 

It  is  difficult  to  draw  a  distinction  between  benign  and  malignant 
growths  of  the  testicle,  because  histologically  the  tumors  are  nearly 
alwa3^s  mixed  formations  composed  of  fibrous,  myxomatous,  sarcom- 
atous, and  cartilaginous  elements  associated  together,  and  tumors  of 
the  testicle  which  are  apparently  innocent  are  often  followed  by  sec- 
ondary deposits  in  the  adjacent  lymphatic  glands  and  other  organs. 

VARIETIES  AND  CLASSIFICATION. 

Sarcoma  may  be  composed  of  spindle-  or  round-  cells,  or  may,  in 
its  early  stages,  appear  as  numerous  small  cysts,  filled  with  clear  or 
dark  fluid,  scattered  through  the  substance  of  the  gland. 

Carcinoma  is  usually  of  the  soft,  or  encephaloid,  variety. 

Lymphadenoma,  chondroma,  fibroma,  myxoma,  and  osteoma  are 
also  occasionally  met  with. 

The  clinical  history  of  sarcoma  and  carcinoma,  which  are  by  far 
the  most  common  forms,  may  be  considered  together. 

The  age  at  which  the  disease  usually  appears  is  from  fifteen  to 
forty-five  years,  but  sarcoma  is  occasionally  found  in  very  young 
children. 

The  disease  begins  in  the  glandular  epithelium  of  the  tubes  or 
in  the  connective  tissue  between  the  tubes,  and  increases  in  size,  in- 
volving the  whole  body  of  the  testicle. 

The  tumor  formed  is  smooth  and  uniform,  until  the  tunica  albu- 
ginea  breaks  down^  and  after  this  occurs  the  growth  feels  irregular 
or  nodular,  with  areas  which  are  soft  and  fluctuating.  The  tumor 
increases  more  rapidly  in  size  after  rupture  of  the  tunica  albuginea 
and  often  becomes  enormous.  The  skin  of  the  scrotum  sloughs  and 
allows  parts  of  the  testicle  and  granulations  to  protrude  through  the 
opening,  forming  fungus  testis. 

The  spermatic  cord  enlarges  from  the  infiltration  of  its  tissues  by 
the  new  growth,  and  the  adjacent  lymphatic  glands  become  infected 
and  enlarged. 

The  veins  of  the  scrotum  swell,  and  the  lower  extremities  become 
oedematous  from  the  pressure  of  the  pelvic  and  lumbar  glands  upon 
the  iliac  veins. 

The  general  health  fails,  the  patient  becomes  cachectic  and  ema- 


TUBERCULOSIS  OF  THE  TESTICLE.  247 

ciated,  and  death  results  in  one  or  two  years  after  the  first  appearance 
of  the  growth. 

PROGNOSIS  AND  TREATMENT. 

The  great  majority  of  tumors  of  the  testicle  are  either  malignant, 
tubercular,  or  syphilitic,  and  it  is  always  desirable  to  try  the  effect  of 
inunctions  of  mercury  and  large  doses  of  iodide  of  potash,  for  ten  days, 
if  there  is  any  suspicion  of  syphilis. 

If  there  is  no  improvement  at  the  end  of  that  time,  castration 
should  be  at  once  performed. 

If  this  is  done  early  enough,  the  disease  may  be  permanently 
cured,  but  unfortunately  it  is  not  uncommon  for  the  lymphatic  glands 
in  the  pelvis  to  be  involved,  and  a  recurrence  of  the  disease  often  takes 
place  within  a  year  after  the  operation. 


TUBERCULOSIS  OF  THE  TESTICLE. 

The  testicle  is  frequently  the  seat  of  tuberculosis,  which  always 
begins  in  the  epididymis  and  may  subsequently  involve  the  body  of  the 
testicle. 

The  epididymis  may  be  affected  (a)  primarily,  which  is  most  fre- 
quent; (b)  secondarily  from  a  tubercular  deposit  in  one  of  the  other 
genito-urinary  organs;  or  (c)  in  consequence  of  a  general  tuberculosis. 


CHANNELS  THROUGH  WHICH  TUBERCLE  BACILLI  ARE  CONVEYED 
TO  THE  EPIDIDYMIS, 

When  the  epididymis  is  affected  primarily,  the  bacilli  are  intro- 
duced into  the  general  blood-circulation  and  carried  directly  to  the 
epididymis  by  the  spermatic  artery. 

When  the  infection  in  the  epididymis  is  secondary,  it  is  frequently 
derived  from  the  seminal  vesicles.  These  are  often  affected  by  tuber- 
culosis, as  the  result  of  tubercle  bacilli  which  were  introduced  into  the 
urethra  during  coitus. 

After  the  tubercular  process  is  established  in  the  vesicles  the 
bacilli  are  carried  along  the  vas  deferens  and  lodge  in  the  epididymis. 

If  the  tuberculosis  in  the  epididymis  is  derived  from  the  bladder. 


248 


DISEASES  OF  THE  TESTICLES. 


prostate,  or  other  adjacent  organs,  the  infection  is  usually  carried  by 
means  of  the  Ij^mphatics. 

There  are  certain  predisposing  causes  to  tubercular  infection,  such 
as  hereditary  tendency  to  consumption  and  such  local  causes  as  the 
prolonged  congestion  from  erotic  excitement,  an  attack  of  gonor- 
rhoea, or  slight  traumatism.  These  causes  all  probably  operate  in  the 
same  way,  and  act  by  lowering  the  resistance  of  the  tissues  and  per- 
mitting the  tubercle  bacilli  to  take  effect. 

The  time  of  life  at  which  the  testicle  is  most  liable  to  be  attacked 
is  during  its  period  of  functional  activity,  from  the  age  of  puberty 
until  past  the  fiftieth  year. 

COURSE. 

One  or  two  small  nodules  form  in  the  head  of  the  epididymis. 
Occasionally  they  remain  latent  for  years  or  may  become  encapsulated 
and  converted  into  fibrous  tissue.  As  a  rule,  however,  the  nodules 
grow  and  coalesce  until  the  whole  epididymis  is  so  much  enlarged  that 
it  surrounds  the  testicle.  After  a  time,  the  tubercular  mass  softens, 
becomes  cheesy,  and  breaks  down. 


Fig.  77. — Hernia  or  Fungus  Testis. 


TUBERCULOSIS  OF  THE  TESTICLE.  249 

The  skin  of  the  scrotum  lying  over  the  nodules  is  attached  to  the 
testicle,  glued  fast  by  the  inflammatory  adhesions,  and  the  pus  is  dis- 
charged through  an  opening  in  it  from  the  tubercular  abscess,  leaving 
a  fistula. 

The  disease  seldom  limits  itself  to  the  epididymis,  but,  if  let 
alone,  spreads  to  the  testicle.  This  occurs  in  three-fourths  of  the 
cases,  as  shown  by  autopsy. 

After  the  abscess  in  the  epididymis  or  testicle  has  opened,  a  con- 
siderable amount  of  attached  skin,  lying  over  the  nodule,  may  slough 
away,  leaving  an  opening  in  the  scrotum  through  which  a  mass  of  new 
granulation  tissue,  growing  from  the  testicle  or  tunica  albuginea,  may 
protrude,  forming  hernia  testis,  or  fungus  testis. 

In  the  earlier  stages  of  the  disease,  before  abscess-formation,  the 
tunica  vaginalis  is  affected  by  the  inflammation,  and,  if  an  excess  of 
fluid  is  secreted  by  its  walls,  hydrocele  may  be  present. 

On  the  other  hand,  adhesive  inflammation  may  take  place,  and 
the  sac  of  the  tunica  vaginalis  become  obliterated. 

Occasionally  purulent  collections  containing  tubercle  bacilli  are 
found  in  small  cavities,  circumscribed  by  the  adhesions. 

The  vas  deferens  is  always  affected  in  time,  and  shows  small  local- 
ized nodules  in  its  continuity,  which  are  most  liable  to  be  located  at 
its  extremities, — i.e.,  near  the  seminal  vesicle  and  the  epididymis, — 
the  intermediate  portion  being  free. 

More  rarely  the  cord  is  uniformly  thickened,  with  a  general  dif- 
fuse tubercular  infiltration. 

The  other  testicle  in  time  becomes  affected,  and  the  disease  runs 
its  usual  course. 

Although  tuberculosis  of  the  testicle  usually  runs  a  very  slow 
and  insidious  course,  the  nodules  developing  gradually  until  the  forma- 
tion of  pus,  rare  cases  are  occasionally  met  with  in  which  the  disease 
runs  a  very  acute  course,  called  by  Eeclus  galloping  consumption  of 
the  testicle. 

The  nodules  which  had  existed  quietly  for  a  time  from  some  cause 
take  on  a  very  rapid  growth,  and  caseation  and  abscess-formation  occur 
in  about  three  weeks.  In  this  form  the  testicle  itself  is  always  at- 
tacked, and  it  is  usually  accompanied  by  a  purulent  urethral  discharge 
containing  tubercle  bacilli.  The  discharge  may  originate  spontane- 
ously or  it  may  begin  as  a  gonorrhoea  from  infection  with  gonococci 
during  coitus. 


^50 


DISEASES  OF  THE  TESTICLES. 


SYMPTOMS  AND  DIAGNOSIS. 

Tubercular  nodules  may  exist  in  the  epididymis,  and  remain 
latent  for  months,  without  causing  any  discomfort,  and,  if  discovered, 
they  are  usually  found  accidentally. 

Discomfort  does  not  occur  until  inflammation  begins,  with  its 
pain,  swelling,  and  subsequent  abscess-formation. 

In  the  early  stages  examination  shows  one  or  more  small  nodules 
of  a  peculiar  stony  hardness  to  the  touch  located  in  the  head  of  the 
epididymis  and  along  the  cord. 

Later  in  the  disease,  after  the  nodules  have  become  cheesy  or 
broken  down,  the  skin  is  found  to  be  adherent  over  a  circumscribed 
tumor,  with  hard  walls  and  a  central  softening,  which  may  yield 
fluctuation  if  pus  is  present. 

Although  the  nodule  may  be  actually  located  in  the  epididymis, 
the  enlargement  of  this  part  of  the  organ  is  so  great  that  it  may  sur- 
round the  body  of  the  testicle,  giving  rise  to  an  appearance  as  though 
the  nodule  were  in  the  testicle  itself. 

Suspicions  as  to  the  tubercular  nature  of  a  growth  should  always 
be  aroused  by  the  history  of  an  epididymitis  coming  on  without  any 
apparent  cause  or  after  a  slight  injury,  and,  if  hard  nodules  are  found 
in  the  seminal  vesicles  or  prostate,  the  diagnosis  of  tuberculosis  is 
sufiiciently  established,  and  may  be  confirmed  by  finding  tubercle 
bacilli  in  the  contents  of  the  cheesy  nodules. 

Under  treatment,  the  severe  inflammatory  symptoms  of  epididy- 
mitis quickly  subside,  and  are  usually  followed  by  a  general  softening 
of  the  tumor  and  formation  of  abscess,  differing  in  this  way  from  a 
simple  epidid3'mitis,  which,  after  it  is  over,  leaves  a  hard  and  thick- 
ened epididymis. 

PROGNOSIS 

It  is  a  very  rare  occurrence  for  tuberculosis  of  the  testicle  to 
become  permanently  cured  without  operation,  even  under  the  most 
favorable  climatic  influences. 

When  a  cure  does  occur,  it  is  through  a  process  of  encapsulation 
and  fibroid  degeneration,  but  it  often  happens  that  the  process  of  en- 
capsulation only  closes  up  the  infective  material  for  a  time,  ^nd  under 
favoring  conditions  the  deposit  again  becomes  active  and  continues  its 
usual  course  of  caseation,  abscess-formation,  and  infection  of  remote 
organs. 

Tubercular  nodules,  however,  may  remain  latent  for  many  years 


TUBERCULOSIS  OF  THE  TESTICLE.  251 

before  abscess  forms,  or  until  a  slight  traumatism  or  attack  of  gonor- 
rhoea stirs  them  into  activit)'. 

After  suppuration  the  disease  runs  a  rapid  course,  and  leads  to 
a  fatal  termination  either  by  inducing  tuberculosis  in  some  other  organ 
or  by  the  exhaustion  and  fever  incident  to  the  occurrence  of  sup- 
purating iistulge. 

TREATMENT. 

Palliative  measures  are,  unfortunately,  only  applicable  to  people 
of  means,  who  are  able  to  lead  an  out-of-door  life  or  take  a  long  sea- 
voyage,  and  who  can  have  constant  medical  supervision.  Such  meas- 
ures may  retard  the  caseation  of  the  nodules  if  begun  in  the  earliest 
stage  while  the  deposits  are  small  and  hard. 

As  soon  as  the  deposits  begin  to  soften  and  become  cheesy,  sur- 
gical measures  should  at  once  be  resorted  to,  as  waiting  for  resolution, 
which  never  occurs,  is  only  a  waste  of  valuable  time,  and  allows  the 
extension  of  the  disease  to  remote  organs. 

In  the  case  of  hospital  patients,  who  are  poorly  nourished  and 
badly  housed,  and  Avho  cannot  have  suitable  climatic  surroundings, 
the  nodules  should  be  removed  at  once. 


OPERATIVE  TREATMENT. 

Erasion,  or  curetting,  is  the  operation  which  is  applicable  to  the 
cases  where  one  or  two  small  nodules  exist  in  the  epididymis.  The 
softened  area  should  be  opened  and  the  contents  well  scraped  out  with 
a  sharp  spoon,  iodoform  rubbed  in,  and  the  cavity  packed  and  allowed 
to  heal  by  granulation. 

Castration  is  the  operation  best  adapted  to  the  advanced  cases. 
The  indications  for  its  use  have  been  summarized  by  Jacobson  as  fol- 
lows:— 

(a)  When  erasion  has  failed  in  lesions  of  the  epididymis. 

(b)  When  discharging  fistulfe  are  present  or  are  numerous. 

(c)  When,  after  erasion,  persistent  swelling  of  the  testicle  accom- 
panied with  night-sweats  and  loss  of  flesh  is  present. 

(d)  When  fungus  testis  exists  or  when  the  body  of  the  testicle  is 
involved. 

(e)  In  the  presence  of  purulent  hydrocele. 
Castration  is  used  in  two  different  classes  of  cases: — 

Class  A. — In  primary  tuberculosis,  when  the  disease  is  limited 


252  DISEASES  OF  THE  TESTICLES. 

to  one  testicle  and  has  not  extended  too  high  along  the  cord,  and  when 
the  bladder,  prostate,  and  vesicles  are  not  affected.  In  such  a  case  a 
reasonable  hope  may  be  entertained  that  the  disease  may  be  perma- 
nently eradicated  from  the  body.  If  the  seminal  vesicles  are  affected 
the  indication  for  castration  is  not  so  clear,  although,  if  the  deposits 
are  small  and  of  recent  date  and  the  patient's  general  condition  favors 
rapid  healing,  removing  the  testicle  with  its  diseased  nodules  may 
retard  the  development  of  the  tubercular  foci  located  elsewhere. 

Class  B. — In  cases  where  other  organs  of  the  body  are  tubercular 
and  a  cure  is  impossible,  hygienic  measures  alone  are  the  only  treat- 
ment applicable.  An  exception  should  be  made  to  this  rule  when  the 
testicle  is  disorganized  and  the  scrotum  riddled  with  sinuses  discharg- 
ing pus.  Here  castration  is  indicated  to  relieve  the  patient  from  the 
drain  of  the  exhausting  discharges  and  from  one  source  of  his  discom- 
fort. 

In  the  operation  of  castration  the  infiltrated  skin  and  cellular 
tissue  should  be  removed.  The  spermatic  cord  should  be  divided  as 
high  up  as  possible,  if  necessary  laying  open  the  inguinal  canal  and 
removing  the  cord  as  far  as  the  internal  ring. 

The  cord  should  be  tied  with  a  double  ligature  through  it,  as  a 
single  ligature  is  liable  to  slip  off  and  cause  fatal  ha}morrhage. 


SYPHILIS  OF  THE  TESTICLE. 

The  testicle  is  attacked  by  syphilis  in  the  late  secondary  and 
tertiary  periods,  which  presents  itself  in  two  forms : — 

(a)  Interstitial  or  diffuse  form  consists  in  an  infiltration  of  the 
connective  tissue  between  the  tubules,  which  becomes  converted  into 
a  hard,  fibrous  induration,  which  compresses  and  destroys  the  tubules, 
and  an  atrophy  of  the  entire  organ  results. 

(b)  Circumscribed  or  gummatous  form  is  a  deposit  of  gum- 
matous nodules  varying  in  size  from  a  pin-head  to  a  hen's  egg.  After 
they  have  enlarged  to  a  considerable  size  the  mechanical  compression 
of  the  cortex  causes  a  cheesy  degeneration  of  the  substance  and  a  con- 
traction of  the  nodule,  or  the  centre  becomes  softened  and  is  dis- 
charged through  an  ulcerated  opening  in  the  skin  of  the  scrotum. 

The  epididymis  may  be  involved  secondarily  in  both  forms,  and 


SYPHILIS  OF  THE  TESTICLE.  253 

hydrocele  usually  occurs  from  an  effusion  of  fluid  into  the  sac  of  the 
tunica  vaginalis. 

SYMPTOMS  AND  COURSE. 

The  hody  of  the  testicle  enlarges  slowly  and  insidiously,  without 
causing  any  pain  and  it  often  becomes  as  large  as  an  orange. 

In  shape  its  outline  is  regular,  although  the  protuberance  of  a  cir- 
cumscribed gumma  may  sometimes  be  felt.  Its  consistence  is  dense, 
and  it  feels  heavy.    The  spermatic  cord,  as  a  rule,  is  not  thickened. 

The  scrotum  is  not  affected  until  after  the  gumma  breaks  down, 
when  it  becomes  adherent,  inflames,  and  ulcerates,  and  fungus  testis 
forms. 

The  disease  is  seldom  bilateral  at  the  beginning,  but  the  other 
testicle  may  be  attacked  later. 

Sterility  only  results  from  advanced  disease  in  both  organs,  as  a 
part  of  the  secreting  substance  of  the  gland  is  spared. 


DIAGNOSIS. 

Syphilitic  testicle  is  liable  to  be  mistaken  for  tuberculosis,  neo- 
plasms, gonorrhoeal  epididymitis,  or  hematocele. 

■  The  distinguishing  points  in  syphilis  are  the  regular  outline  and 
smooth,  hard  surface,  and  the  fact  that  the  cord  is  not  enlarged,  and 
in  addition  the  history  of  a  past  attack  of  syphilis. 

The  diagnosis  may  be  confirmed  by  the  effects  of  antisyphilitic 
treatment,  and  this  should  be  tried  in  every  case  of  tumor  of  the  tes- 
ticle before  proceeding  to  operation,  if  there  is  the  slightest  question 
of  a  previous  syphilitic  infection. 


PROGNOSIS. 

Under  appropriate  treatment  syphilitic  infiltration  is  absorbed, 
and  it  is  surprising  to  note  how  quickly  large  swellings  disappear,  and 
the  function  of  the  testicle  is  restored. 

In  untreated  persons — particularly  in  tubercular,  alcoholic,  and 
weakly  individuals — the  gummata  break  down  and  discharge  and  her- 
nia testis  follows,  but  even  neglected  cases,  which  present  ulceration 
of  the  scrotum  and  large  fungus  testis,  generally  heal  in  from  four 
to  six  weeks  under  antisyphilitic  treatment. 


254  DISEASES  OF  THE  TESTICLES. 

TREATMENT. 

The  treatment  consists  in  a  general  course  of  mercurial  inunctions 
and  the  internal  administration  of  iodide  of  potash  in  increasing  doses, 
running  it  up  to  V2  ounce  per  day,  if  necessary,  to  cause  absorption 
of  the  newly-formed  tissue. 


HYDROCELE,  HAEMATOCELE,  AND 
VARICOCELE. 


CHAPTER  XVIIL 

HYDROCELE. 

Before  the  testicle  descends  from  the  abdominal  cavity  in  the 
foetus  it  is  preceded  by  a  process  of  peritoneum,  which  makes  its 
way  through  the  inguinal  canal  and  forms  a  pouch  in  the  scrotum 
called  the  tunica  vaginalis  testis.  After  the  testicle  has  descended 
it  lies  lehind  the  pouch,  and  is  adherent  to  it. 

Under  ordinary  conditions  the  opening  in  the  pouch  which 
formerly  communicated  with  the  abdominal  cavity  is  closed.  If  it 
remain  open,  congenital  hydrocele  is  said  to  exist.  If  the  opening 
closes,  the  testicle  is  provided  with  a  shut  sac,  lying  in  front  of  it 
and  partly  surrounding  it,  which  serves  as  a  protection  against  in- 
juries, and  allows  of  a  certain  freedom  of  motion. 


ACUTE  HYDROCELE. 

ETIOLOGY. 

Acute  hydrocele  is  usually  the  result  of  a  contusion  of  the 
testicle  or  a  punctured  wound  of  the  sac  of  the  tunica  vaginalis. 
It  may  also  occur  from  an  extension  of  inflammation  from  the  epi- 
didymis or  testicle,  occurring  in  the  course  of  gonorrhoea  or  other 
infectious  disease. 

PATHOLOGY. 

Its  pathology  consists  in  an  accumulation  of  serous  fluid,  which 

is  occasionally  stained  with  blood  in  the  sac,  and  a  deposit  of  lymph 

upon  its  walls. 

(255) 


256  HYDROCELE,  HEMATOCELE,  AND  VARICOCELE. 

SYMPTOMS. 

The  symptoms  consist  in  oedema  and  redness  of  the  scrotum,  ac- 
companied by  an  elastic  painful  swelling,  which  is  tender  on  press- 
ure over  the  testicle. 

If  much  fibrin  is  deposited,  crepitation  is  sometimes  observed. 
Acute  hydrocele  terminates  either  in  (a)  recovery  in  two  to  three 
weeks,  with  the  formation  of  adhesions  within  the  sac  and  a  thick- 
ening of  its  walls;  (&)  in  suppuration;  or  (c)  it  may  become  chronic. 


TREATMENT. 

The  treatment  consists  in  rest,  with  suspension  of  the  scrotum 
and  the  local  use  of  an  ice-bag  or  hot  application.  After  the  acute 
S3^mptoms  have  subsided  the  patient  can  walk  about,  wearing  a 
suspensory  bandage.  If  much  fluid  is  present  in  the  sac  and  tension 
is  extreme,  aspiration  is  required. 


ACUTE  PURULENT  HYDROCELE. 

It  occasionally  happens  that  a  fibroserous  hydrocele  becomes 
purulent  instead  of  resolving,  or  suppuration  may  occur  early  as  a 
result  of  an  infected  puncture  of  the  sac,  or  an  extension  of  a 
suppurative  process  from  the  testicle  or  epididymis. 

In  such  a  case  the  contents  of  the  sac,  instead  of  being  clear 
serum,  is  composed  of  pus.  Such  a  condition  is  apt  to  result  in 
involvement  of  the  peritoneum  or  a  general  septic  infection,  unless 
the  pus  is  evacuated  by  a  free  incision  and  drainage. 


CHRONIC  HYDROCELE. 

Chronic  hydrocele  is  generally  confined  to  one  side,  and  ordi- 
narily occurs  between  the  twentieth  and  fortieth  years,  although 
children  are  occasionally  born  with  it.  It  sfenerally  begins  insidi- 
ously, although  it  may  follow  an  acute  attack. 

It  is  supposed  to  be  a  mere  passive  process  of  transudation  de- 


Fig.  78.— Hydrocele.     (Author's  Case,  from  Kings  County  Hospital.) 


(257) 


CHRONIC  HYDROCELE. 


259 


Fig.  79. — Vertical  Section  of  Simple  Hydrocele. 

pendent  upon  the  state  of  the  blood-vessels  and  circulation,  when 
it  occurs  as  a  primary  disease. 

PATHOLOGY. 

The  quantity  of  fluid  which  the  sac  contains  is  variable,  from  a 
few  ounces  to  one,  two,  or  even  three  quarts.  Its  color  is  usually  clear 
and  watery,  but  it  may  be  greenish  or  bloody.  If  it  contain  a  large 
number  of  desquamated  epithelial  cells  and  leucocytes,  it  appears 
turbid,  and  blood  gives  it  a  reddish  or  brown  color. 

In  rare  cases  the  fluid  is  white,  and  resembles  milk,  from  an  ad- 
mixture with  lymph  (hydrocele  chylosa),  and  in  the  tropics,  and  in 
cases  of  true  elephantiasis,  filiaria  are  found  in  the  milk-like  contents 
of  the  sac. 

In  long-standing  cases  of  chronic  hydrocele  the  tunica  vaginalis 
is  thickened,  and  may  be  calcified  in  portions,  and  the  testicle  and 
epididymis  are  hard  and  atrophied. 

Sometimes  adhesions  form,  and  the  sac  is  converted  into  a  num- 
ber of  distinct  compartments.  In  other  cases  small  fibrous  or  fibro- 
cystic bodies  are  attached  to  the  wall  or  lie  loosely  within  the  sac. 


k 


260 


HYDROCELE,  H^EIMATOCELE,  AND  VARICOCELE. 


SYMPTOMS  AND  DIAGNOSIS. 

Hydrocele  causes  no  symptoms  except  those  which  arise  from 
the  increase  in  size  and  weight  of  the  scrotal  enlargement. 

On  palpation,  the  tumor  is  found  to  be  pear-shaped  and  elastic 
to  the  touch,  dull  on  percussion,  without  impulse  on  coughing,  and 
it  cannot  be  reduced  and  returned  into  the  abdomen. 

Attention  to  these  points  will  usually  differentiate  a  hydrocele 
from  a  hernia,  hsematocele,  neoplasm  of  the  testicle,  or  a  hydrocele 
of  the  cord. 

An   additional   point   in   diagnosis   is   the   translucency   of   the 


t^>i. 


Fig.  80. — Hydrocele  Complicated  by  Hernia. 

hydrocele  when  it  is  viewed  through  a  tube  with  a  candle  placed  on 
the  other  side  of  the  scrotum. 

This  sign  is  not  infallible,  however,  as  the  thickened  walls  of 
the  sac  or  turbidity  of  its  contents  from  pus  or  blood  prevent  the 
light  from  being  transmitted. 

As  a  last  resource  in  diagnosis  a  suspected  hydrocele  may  be 
aspirated  with  a  fine  needle,  or  the  patient  may  be  prepared  for 
operation  and  the  contents  of  the  scrotum  exposed  by  an  incision. 


TREATMENT. 


The  spontaneous  healing  of  a  hydrocele  in  an  adult  is  such 
a  rare  occurrence  that  operation  is  always  called  for. 


CHRONIC  HYDROCELE. 


261 


Puncture  with  a  trocar  may  be  regarded  as  palliative  only,  for 
the  sac  always  fills  up  again  with  fluid  in  a  short  time. 

Technique.— The  scrotum  is  grasped  in  the  hand  and  made  tense, 
and  after  locating  the  position  of  the  testicle,  which  is  usually  a 
little  below  and  lying  behind  the  sac,  the  trocar,  with  its  point  di- 
rected obliquely  upward  and  inward,  is  thrust  into  the  swelling,  and 
the  fluid  is  withdrawn. 


Fig.  81. — Tapping  a  Hydrocele. 

Radical  Treatment  by  Injection. — This  is  successful  in  many 
cases  of  hydrocele  of  moderate  size  and  where  the  walls  of  the  sac  are 
not  thickened,  although  it  is  more  liable  to  be  followed  by  a  relapse 
than  after  incision. 

The  advantages  of  injection  are  that  no  anaesthetic  is  required 
and  the  patient  is  only  confined  to  the  house  three  or  four  days. 

Technique. — A  hypodermic  syringe  is  filled  with  30  drops  of 
pure  carbolic  acid,  and  the  needle  is  introduced  into  the  cavity  of 
the  sac.  The  hydrocele  is  then  tapped  with  a  trocar  in  the  ordinary 
way,  and  the  fluid  drawn  o£P  entirely.  It  is  necessary  that  the  sac 
should  be  completely  emptied,  for,  if  fluid  is  left  in,  the  carbolic 
acid  is  diluted,  so  that  it  does  not  produce  the  necessary  amount  of 
irritation,  and  if  diluted  it  may  be  absorbed  and  cause  poisoning. 

After  the  fluid  is  drawn  off  the  carbolic  acid  should  be  injected, 
through  the  hypodermic  needle,  which  has  remained  in  situ,  and 


262  HYDROCELE.  HiEMATOCELE,  AND  VARICOCELE. 

the  carbolic  acid  is  not  withdrawn,  but  left  in  the  sac.  Inflamma- 
tory reaction  is  excited,  but  the  exudate  is  gradually  absorbed,  and 
the  sac  becomes  obliterated  by  the  formation  of  adhesions  between 
its  visceral  and  parietal  walls. 

Incision  of  the  sac  is  preferred  to  the  treatment  by  injection 
in  the  following  cases  (Morris): — 

I.  When  the  sac  is  very  thick,  opaque,  cartilaginous,  or  calcified. 

II.  If  doubt  exists  as  to  whether  the  hydrocele  is  congenital  or  is 
a  hydrocele  of  a  hernial  sac  with  a  small  opening  into  the  peritoneum. 

in.  When  a  hernia  complicates  hydrocele  and  a  radical  cure  of 
both  is  desired. 

IV.  When  a  loose  or  pedunculated  fibrous  body  is  present  in 
the  tunica  vaginalis. 

V.  When  organic  disease  of  the  testicle  is  suspected. 

VI.  When  on  account  of  ill  health  or  lessened  resistance  the 
risk  of  inflammation  after  injection  is  especially  to  be  dreaded. 

There  are  two  methods^  of  performing  the  operation  of  incision: 
(a)  Volkmann's  Operation  of  Simple  Incision. — In  this  proced- 
ure the  sac  is  opened  by  a  longitudinal  incision  through  the  scrotum, 
and  after  the  fluid  is  evacuated  the  edges  of  the  walls  of  the  sac  are 
stitched  to  the  edges  of  the  wound  in  the  skin,  to  prevent  leakage 
into  the  cellular  tissue  of  the  scrotum.  The  cavity  of  the  sac  is 
packed  and  allowed  to  heal  by  granulation,  and  in  this  way  the  sac 
becomes  obliterated.  The  patient  is  able  to  get  out  of  bed  in  a 
week,  and  the  wound  is  healed  by  about  the  third  week. 

(6)  Von  Bergmann's  Operation  of  Incision  and  Excision  of  the 
Tunica  Vaginalis. — Tillmanns  considers  this  the  best  radical  opera- 
tion. The  sac  is  laid  bare  by  a  longitudinal  incision,  and  by  blunt 
dissection  is  freed  from  the  cellular  tissue.  The  redundant  portion 
of  the  sac  is  then  cut  away  with  scissors  from  the  testicle,  but  leav- 
ing enough  of  the  wall  of  the  sac  to  cover  the  testicle  itself.  The 
external  wound  is  closed  with  sutures,  and  a  dressing  applied  which 
will  exert  compression.  The  wound  is  cicatrized  in  from  eight  to 
twelve  days.  Eelapses  are  more  certainly  prevented  through  excision 
than  by  other  methods,  and  the  wound  heals  in  a  very  short  time. 


^  An  excellent  operative  procedure  recently  suggested  by  Doyen  for  thin- 
walled  hydroceles  consists  in  incising  the  sac  and  everting  the  testicle  so  that 
it  lies  outside  the  sac.  The  wound  in  the  sac  is  then  sutured  to  prevent  the 
return  of  the  hydrocele,  and  the  incision  in  the  scrotum  is  closed  without 
drainace. 


HYDROCELE  OF  THE  SPERMATIC  CORD.  2G3 

HYDROCELE  OF  THE  SPERMATIC  CORD. 

(a)  The  cystic  form  is  found  as  one  or  more  small  cysts,  which 
form  in  the  sheath  of  the  cord,  along  its  course  hetween  the  testicle 
and  the  internal  ring.  The  cysts  are  caused  by  an  effusion  of  serous 
fluid  into  some  part  of  the  processus  vaginalis,  which  was  not  obliter- 
ated after  the  descent  of  the  testicle. 

The  cysts  usually  occur  between  the  testicle  and  external  ring, 
and  may  extend  so  far  down  into  the  scrotum  as  to  displace  the 
testicle  to  one  side;  in  a  few  cases  the  cyst  lies  within  the  inguinal 
canal. 

Occasionally  the  cyst  forming  a  hydrocele  of  the  cord  is  not 
closed  at  either  end,  but  communicates  with  the  tunica  vaginalis  and 
also  the  peritoneal  cavity  (communicating  hydrocele  of  the  cord), 
and  it  is  a  frequent  occurrence  for  the  cyst  to  communicate  with 
the  sac  of  the  tunica  vaginalis  testis.  The  cysts  are  shaped  like  an 
egg,  and  range  in  size  from  a  pea  to  a  hen's  egg. 

(b)  The  diffuse  form  of  hydrocele  of  the  cord  is  of  extremely 
rare  occurrence,  and  consists  in  an  oedematous  infiltration  of  the 
entire  sheath  of  the  cord,  ceasing  abruptly  at  the  testicle  below.  The 
chief  importance  of  hydrocele  of  the  cord  is  from  a  diagnostic  stand- 
point: in  differentiating  it  from  cryptorchism  or  hernia. 


TREATMENT. 

The  use  of  injections  of  carbolic  acid  is  attended  with  some 
danger,  as  the  cyst  may  communicate  with  the  peritoneal  cavity  and 
the  carbolic  acid  may  flow  back  into  the  abdominal  cavity. 

Operation  is  usually  called  for,  and  consists  in  division  of  the 
common  sheath  of  the  cord,  in  a  longitudinal  direction,  and  exsec- 
tion  of  as  much  of  the  sac  as  can  be  separated  from  the  cord.  If  the 
sac  is  found  to  be  open,  communicating  with  the  peritoneal  cavity,  it 
is  necessary  to  close  the  inguinal  canal  by  suturing  the  upper  edge  to 
Poupart's  ligament,  as  in  Bassini's  operation  for  hernia.  If  this  were 
not  done,  the  omontnm  and  gut  would  subsequently  descend  through 
the  patulous  inguinal  canal,  and  cause  hernia. 


8(54  HYDROCELE,  HEMATOCELE,  AND  VARICOCELE. 


H-ffiMATOCELE. 

Hsematocele  is  the  name  given  to  the  tumor  which  forms  when 
a  haemorrhage  occurs  (a)  into  the  sac  of  the  tunica  vaginalis  (vaginal 
hasmatocele),  or  (6)  into  the  scrotal  tissues  around  the  testicle  (ex- 
travaginal  haematocele),  or  (c)  with  the  sheath  of  the  spermatic  cord 
(hematocele  of  the  cord). 

ETIOLOGY. 

A  predisposing  cause  in  the  shape  of  disease  of  the  walls  of  the 
tunica  vaginalis  or  of  the  testicle  is  very  apt  to  be  present. 

The  exciting  cause  of  the  hsemorrhage  is  always  traumatism, 
which  may  be  slight,  such  as  coughing,  sneezing,  or  straining  at 
stool, — or  it  may  be  severe  and  the  result  of  a  blow  or  kick  upon 
the  scrotum  or  the  accidental  puncture  of  the  testis  with  a  trocar  in 
tapping  a  hydrocele. 

SYMPTOMS  AND  COURSE. 

Swelling  of  the  scrotum  takes  place  very  quickly  after  the  in- 
jury, and  a  tumor  forms,  which  is  a  hard,  smooth,  globular  swelling 
surrounding  the  testicle.  After  a  few  days  inflammatory  thickening 
of  the  tissues  occurs,  and  the  hasmatocele  is  liable  to  be  mistaken 
for  a  neoplasm  of  the  testicle. 

The  blood-clot  may  remain  for  years  without  being  absorbed, 
in  which  case  the  walls  of  the  tunica  vaginalis  become  thick  and 
dense,  and  the  testicle  undergoes  atrophy.  On  the  other  hand,  the 
clot  may  become  infected,  and  suppuration,  ending  in  abscess,  occurs. 


TREATMENT. 

In  recent  cases  a  moderate  effusion  of  blood  may  be  absorbed 
with  the  assistance  of  rest  in  bed,  elevation  of  the  scrotum,  and 
25-  to  50-per-cent.  ointment  of  ichthyol;  but  spontaneous  absorptioa 
is  of  seldom  occurrence,  and  operation  is  usually  necessary. 

The  operative  treatment  consists  in  laying  open  the  sac  by  a 
free  incision  and  evacuating  the  blood-clot.  The  sac  of  the  tunica 
vaginalis  may  afterward  be  treated  as  a  hydrocele,  and  either  ex- 
sected  or  its  cavity  packed  and  allowed  to  granulate. 


VARICOCELE.  £65 


HiEMATOCELE  OF  THE  SPERMATIC  COED. 

This  is  a  rare  affection,  and  may  occur  from  direct  violence  or 
from  the  strain  of  lifting  a  heavy  weight,  even  though  the  cord  is 
perfectly  healthy. 

A  fusiform  swelling  rapidly  develops  along  the  cord,  which  is 
easily  mistaken  for  hernia.  After  a  few  hours  the  swelling  becomes 
hard  and  tense,  with  ecchymoses  into  the  surrounding  tissues,  and 
the  diagnosis  is  made  clear. 

The  treatment  is  conducted  on  the  same  lines  as  for  htematocele 
of  the  tunica  vaginalis. 


VARICOCELE. 

Varicocele  is  an  abnormal  dilatation  of  the  veins  of  the  sper- 
matic cord,  and  is  analogous  to  the  varicosities  which  occur  in  the 
veins  of  the  lower  extremities. 

A  slight  varicocele  often  disappears  spontaneously  after  mar- 
riage, when  sexual  intercourse  is  duly  regulated  and  also  in  old  age. 


ETIOLOGY. 

The  causes  of  varicocele  are,  in  a  general  way,  those  of  varicosi- 
ties elsewhere;  prolonged  standing,  ungratified  sexual  excitement 
continued  for  some  time,  and  constipation,  all  tend  to  cause  passive 
congestion  and  disturbance  of  the  circulation,  with  increase  of  hydro- 
static pressure  in  the  veins  of  the  cord. 

The  spermatic  veins  are  more  liable  to  enlarge  than  others,  be- 

!  cause  their  valves  are  insufficient  to  uphold  the  long  column  of  blood, 

I  which  also  derive  but  little  external  support  from  the  loose  cellular 

(  tissue  of  the  scrotum  in  which  they  lie. 

I  Billroth  believes  that  there  is  an  inherited  predisposition  to  the 

formation  of  varicosities,  which  is  first  manifested  in  the  spermatic 

i  veins,  and  later  in  those  of  the  rectum  and  legs. 

Varicocele  occurs  most  frequently  on  the  left  side,  because,  while 

)  the  right  spermatic  vein  enters  the  vena  cava  at  a  sharp  angle,  tho 

j  left  spermatic  vein,  after  passing  underneath  the  sigmoid  flexure, 


266  HYDROCELE,  HEMATOCELE,  AND  VARICOCELE. 

empties  at  a  right  angle  into  the  left  renal  vein.  The  pressure 
exerted  by  the  colon  and  the  right-angled  insertion  of  the  vein  tend 
to  impede  the  current  of  blood,  and  cause  an  increase  in  the  hydro- 
static pressure,  which  is  greater  on  the  left  side  than  on  the  right. 


SYMPTOMS. 

In  robust  and  vigorous  men  varicocele  of  moderate  size  causes 
but  little  discomfort,  at  most  only  a  sense  of  weight  and  dragging  iu 
the  spermatic  cord,  after  long  standing,  walking,  riding,  or  any 
sudden  exertion.  These  things  all  exaggerate  the  swelling  of  the 
veins,  and  the  discomfort  from  them  is  always  increased  toward 
evening. 

In  young  men  who  are  weak  or  ansemic  or  who  have  previously 
masturbated  excessively,  a  feeling  of  fullness  and  burning  in  the 
scrotum  and  cord,  accompanied  by  pains  radiating  into  the  abdomen 
and  occasionally  marked  neuralgia  of  the  testicle,  is  often  met  with. 
Such  individuals  are  frequently  sexual  hypochondriacs,  and  suffer 
from  mental  depression  and  the  fear  of  impaired  virility,  or  even 
impotence,  arising  from  the  varicocele.  They  should  be  taught  to 
regard  the  varicocele,  if  moderate  in  size,  with  indifference,  as  it  has 
a  natural  tendency  to  subside  as  age  advances  and  particularly  after 
the  regulated  coitus  of  marriage  is  instituted. 

It  is  only  in  cases  of  very  pronounced  varicocele,  where  tlie  cir- 
culation is  materially  impaired,  that  serious  atrophy  of  the  testicle 
occurs,  although  in  every  case  of  varicosities  of  the  cord  the  circula- 
tion in  the  testicle  is  somewhat  interfered  with,  and  it  is  softer  and 
smaller  than  normal. 

The  spermatic  vein  may  become  the  seat  of  disease,  and  in  rare 
cases  thrombosis,  phlebitis,  gangrene,  etc.,  may  occur. 

DIAGNOSIS. 

The  diagnosis  of  varicocele  is  usually  easy,  and  the  veins  in 
the  scrotum  feel  like  a  bunch  of  angle-worms.  In  very  marked  cases 
the  enlarged  blue  veins  can  be  seen  shining  through  the  skin  of  the 
scrotum.  In  cases  of  moderate  severity  the  testicle  is  slightly  flabby 
and  the  skin  of  the  scrotu^n  relaxed. 

If  the  patient  lies  down,  the  swelling  disappears,  not  suddenly, 
like  a  hernia,  but  more  gradually,  and  almost  imperceptibly;  and, 
if   he    stands   upright   again,    pressure    with    the    finger    over    the 


Fig.  82. — Varicocele.    (Author's  Case,  from  Kings  County  Hospital.) 


(267) 


VARICOCELE. 


269 


external  ring  does  not  prevent  the  veins  from  refilling  with  hlood, 
whereas  in  hernia  the  omentum  is  prevented  from  descending  by 
pressure  over  the  ring. 


TREATMENT. 

Palliative  treatment  is  all  that  is  required  in  varicocele  of  mod- 
erate size  and  which  causes  but  little  discomfort.  The  scrotum  should 
be  supported  with  a  well-fitting  suspensory  bandage,  and,  locally,  cold 
douching  is  of  service  in  giving  tone  to  the  muscles.  Constipation 
should  be  prevented,  and  the  patient  should  avoid  erotic  excitement 
or  too  frequentjcpitus. 

Operation  is  required  only  in  marked  cases,  when  the  support  of 
a  suspensory  bandage  is  not  sufficient  to  remove  the  annoyance  of 
weight  and  dragging,  after  walking  or  long  standing,  or  in  cases  where 
a  considerable  degree  of  enlargement  of  the  veins  exists.  Operation 
is  also  called  for,  in  persons  desiring  to  enter  the  army,  navy,  or  police 
service,  in  which  any  degree  of  varicocele  is  regarded  as  a  disability. 

The  operation  of  subcutaneous  ligation  of  the  veins  is  popular 
with  some  surgeons.  It  has  the  advantage  that  the  time  of  convales- 
cence is  a  little  shortened,  but  its  disadvantages  are  weighty.  A  vein 
is  very  liable  to  be  punctured,  and  an  haematocele  occurs.  The  silk 
ligature  remains  permanently,  becomes  imbedded  in  scar-tissue,  and 
sometimes  causes  persistent  neuralgia,  making  it  necessary  to  open  up 
the  wound  and  exsect  the  knot,  or  the  knot  may  slip  and  the  vein  is 
not  occluded.  The  danger  of  tying  in  the  spermatic  cord  exists,  but 
can  be  guarded  against  by  due  care  in  holding  the  cord  out  of  the  way. 

Eelapses  occur  with  greater  frequency  after  subcutaneous  liga- 
tion than  after  excision. 

Excision  of  a  portion  of  the  veins  is  the  operation  to  be  preferred, 
and  the  patient  is  only  kept  in  bed  for  a  week  or  ten  days.  By  the 
open  operation  it  is  possible  to  avoid  all  the  dangers  attendant  upon 
the  subcutaneous  ligation. 

Technique. — The  patient  is  etherized,  and  an  incision  made  over 
the  bunch  of  veins,  beginning  near  the  external  inguinal  ring  and  ex- 
tending two  inches  down  over  the  scrotum.  The  veins  are  exposed  by 
dissection  and  ligated  in  two  places,  about  an  inch  apart.  The  por- 
tion of  the  veins  lying  between  the  ligatures  is  then  cut  out  with 
scissors,  and  the  cut  ends  of  each  portion  of  the  vein  are  brought 
together  into  apposition  and  held  so,  by  tying  the  ends  of  the  liga- 


270  HYDROCELE,  HEMATOCELE,  AND  VARICOCELE.  . 

tures  together,  and  in  this  wa}^  the  vein  is  shortened.  The  wound  is 
then  closed  by  sutures. 

The  patient  is  kept  in  bed  for  a  week,  and  on  a  sofa  for  another 
week,  and  after  the  third  week  is  completed  he  can  begin  his  active 
labors,  and  the  same  length  of  time  should  elapse  after  the  subcuta- 
neous ligation. 

After  either  operation  a  hard  mass  remains  in  the  scrotum,  com- 
posed of  coagula  in  the  veins  and  infiltration  around  them.  This  is 
absorbed  and  disappears  in  from  two  to  four  months.   • 

Atrophy  of  the  testicle  exceptionally  follows  either  operation, 
even  when  the  cord  is  not  included  in  the  ligature. 


CHANCROID  AND  ITS  COM- 
PLICATIONS. 


CHAPTER   XIX. 

CHANCEOID. 

Synonyms. — Soft  chancre,  or  simple  venereal  ulcer. 


ETIOLOGY. 

There  are  at  present  two  views  held  in  regard  to  the  etiology  of 
chancroid:  (a)  It  is  supposed  by  some  to  be  due  to  a  particular  micro- 
organism produced  in  another  chancroid,  which  is  named,  after  its 
discoverer,  the  bacillus  of  Ducrey.    (&)  The  other -view,  which  is  more 


€h 


Fig.  83.— Section  of  Chancroid,  showing  Ducrey's  Bacillus,  which  has 
the  form  of  small  rods  arranged  in  chains. 

generally  held,  is  that  chancroid  is  merely  an  active  form  of  wound- 
infedion,  and  that  it  is  caused  by  the  inoculation  under  the  skin  of 
a7iy  of  the  pus-producing  micro-organisms,  and  in  this  and  other  re- 
spects resembles  clinically  impetigo  contagiosa  or  ecthyma. 

(271) 


273  CHANCROID  AND  ITS  COMPLICATIONS. 

MODES  OF  CONTAGION. 

(a)  Immediate:  i.e.,  through  direct  contact,  as  in  coitns,  or  by 
digital  examination,  etc. 

(b)  Mediate,  in  which  contact  is  not  made  with  the  chancroid, 
but  some  of  the  pus  is  deposited  upon  an  instrument,  towel,  chamber 
utensil,  water-closet  seat,  etc.,  and  from  this  point  is  brought  into 
contact  with  another  person,  who  becomes  infected. 

The  pus  from  a  chancroid  is  acrid  and  irritating,  and  has  the 
property  of  softening  and  corroding  the  healthy  epidermis;  so  that 
an  abraded  surface  is  not  essential  for  the  entrance  of  the  micro- 
organisms under  the  skin. 

FREQUENCY  OF  CHANCROID. 

Chancroid  is  more  common  among  the  lower  classes  than  among 
cleanly  and  well-nourished  people,  as  its  development  is  favored  by 
filthy  habits  and  dirty  surroundings,  and  all  the  accompaniments  of 
privation  and  misery. 

COURSE. 

Chancroid  is  usually  multiple,  although  it  sometimes  exists  singly. 
The  fact  of  the  sores  being  multiple  is  accounted  for  in  the  following 
ways : — 

(a)  A  number  of  points  are  inoculated  with  chancroidal  pus  at 
the  time  of  contagion. 

(b)  Through  autovnoculation. 

Autoinoculation  may  be  defined  as  the  action  of  pus  formed  in 
one  chancroid  producing  other  chancroids  in  the  same  individual:  i.e., 
the  inoculation  of  the  patient  with  pus  from  his  own  chancroid. 

After  inoculation,  in  about  twenty-four  hours  several  pustules 
appear,  which  spread  at  the  margins;  the  tissues  adjacent  are  involved 
and  break  down,  and  the  ulceration  extends. 

CHARACTERISTICS. 

In  chancroid  there  is  no  period  of  incubation,  and  it  is  generally 
noticed  on  the  third  day  after  "coitus. 

The  location  is  usually  on  the  genitals,  although  it  exceptionally 
occurs  on  the  fingers. 

In  shape  the  sore  is  usually  irregular,  although  it  may  be  round 
or  oval. 

Number. — It  is  exceptional  for  chancroids  to  exist  singly.    They 


Fig.  84.— Chancroids  of  the  Prepuce.     (Author's  Case,  from 
Kings  County  Hospital.) 


(273) 


CHANCROID.  275 

are  usually  muUipU,  either  from  the  simultaneous  inoculation  of  sev- 
eral points  at  first  or  from  subsequent  autoinoculation. 

Pain  is  usually  present  to  a  considerable  extent. 

The  base  of  the  sore  in  a  typical  case  is  devoid  of  induration,  but 
if  an  excessive  amount  of  inflammation  has  taken  place — as  a  result 
of  insufficient  and  frequent  cauterization,  prolonged  contact  with  irri- 
tating urine,  pus,  or  acrid  secretions — an  inflammatory  or  boggy  hard- 
ness is  often  present.  This  does  not  feel  like  the  induration  of  a 
chancre,  which  is  sharply  defined  and  which  resembles  a  piece  of  carti- 
lage under  the  skin,  but  is  doughy  or  boggy  in  feeling,  and  shades  off 
gradually  into  the  surrounding  tissues. 

The  floor  of  the  chancroid  is  rough  and  uneven,  and  covered  with 
a  dirty-grayish  deposit. 

The  edges  of  the  sore  are  undermined,  and  the  discharge  is  abun- 
dant, purulent,  and  sometimes  bloody. 

Duration  of  the  chancroid  may  be  divided  into  stages: — 

/.  Progressive  stage,  during  which  each  sore  extends  by  a  break- 
ing down  and  ulceration  of  the  edges,  and  fresh  sores  are  continually 
forming  as  a  result  of  autoinoculation. 

II.  Stationary  stage.  After  a  time  the  pus  loses  its  virulence, 
autoinoculation  of  fresh  surfaces  no  longer  occurs,  and  the  ulcers  cease 
to  increase  in  size,  but  remain  stationary. 

///.  The  reparative  stage  begins  when  the  sores  are  covered  with 
healthy  granulations  and  cicatrization  is  in  progress. 

The  various  stages  require  about  six  weeks  in  time  for  uncom- 
plicated cases,  but  relapses  from  autoinoculation  are  very  frequent, 
and  delay  the  healing  process. 

Microscopic  examination  of  a  chancroid  shows  it  to  be  composed 
of  a  small  round-celled  infiltration  which  takes  place  in  the  skin  and 
subcutaneous  tissues,  and  which  leads  in  time  to  coagulation-necrosis. 

The  lymphatics  are  not  involved,  but  remain,  open  and  gaping, 
ready  to  convey  micro-organisms  or  toxins  to  the  nearest  lymphatic 
gland,  and  in  this  way  we  can  account  for  the  frequent  occurrence  of 
bubo. 

Until  1852,  chancroid  was  regarded  as  a  syphilitic  manifestation; 
yet  the  true  difference  between  the  two  diseases  w^ould  have  been 
sooner  discovered  but  for  the  mixed  sore.  It  sometimes  happens  that 
an  individual  is  syphilitic  and  has  accidentally  acquired  chancroids. 

As  a  result  of  contact  with  both  poisons,  usually  during  coitus, 
another  person  receives  a  double  infection:   i.e.,  the  virus  of  syphilis 


276  CHANCROID  AND  ITS  COMPLICATIONS. 

and  that  of  chancroid  are  both  inoculated  at  the  same  moment.  The 
chancroid  appears  in  twenty-four  hours,  but,  on  account  of  the  longer 
incubation  of  syphilis,  the  chancre  is  not  evident  for  at  least  three 
weeks.  After  this  period  has  gone  by,  the  base  of  the  chancroid 
becomes  hard  and  sclerosed  and  the  sore  is  transformed  into  a  true 
chancre  which  is  followed  by  symptoms  of  constitutional  syphilis. 


DIAGNOSIS. 

It  is  often  difficult  to  make  a  differential  diagnosis  between 
chancre  and  chancroid,  particularly  in  the  cases  where  an  excessive 
amount  of  inflammation  has  occurred  and  a  condition  of  boggy  inflam- 
matory induration  is  present.  We  should  always  bear  in  mind  the 
possibility  of  a  mixed  sore  being  present,  and  it  is  usually  well  to  allow 
three  or  four  weeks  to  elapse  before  excluding  syphilitic  infection. 

The  principal  points  to  consider  in  making  a  differential  diag- 
nosis are  as  follow: — 

I.  The  period  of  incubation:  i.e.,  the  time  which  elapses  between 
coitus  and  the  appearance  of  the  sore. 

II.  The  absence  of  the  cartilaginous  induration,  which  character- 
izes the  primary  lesion  of  syphilis. 

III.  The  ragged,  punched-out  appearance  of  the  sores,  which  are 
usually  multiple. 

IV.  The  character  of  the  accompanying  enlargement  of  the  in- 
guinal lymphatic  glands. 

Herpes  praeputialis  is  sometimes  incorrectly  diagnosed  as  chan- 
croid. This  mistake  ought  not  to  occur,  if  due  care  is  used  in  the 
examination.  Herpes  appears  as  a  number  of  small  vesicles,  which 
form  upon  the  glans,  prepuce,  or  skin  of  the  penis.  The  vesicles  soon 
break,  and  leave  small,  round,  superficial  erosions,  which  rapidly  heal 
under  a  simple  dusting-powder. 

TREATMENT. 

(a)  Abortive.  —  If  the  chancroid  is  seen  early  enough,  the  in- 
dication for  treatment  is  to  destroy  the  chancroidal  character  of  the 
sore  and  transform  it  into  a  simple  non-infected  ulcer. 

Methods. — Nitrate  of  silver  should  never  be  used  for  this  purpose, 
as  its  cauterizing  action  does  not  penetrate  deeply  enough  into  the 
substance  of  the  sore. 

The  best  means  to  this  end  is  the  Paquelin  cautery.     Fuming 


CHANCROID.  277 

nitric  acid  or  the  acid  nitrate  of  mercury  applied  to  the  sore  upon  a 
glass  rod  will  answer  the  same  purpose.  The  ulcerating  surfaces 
should  be  washed  clean  and  anesthetized  by  chloride  of  ethyl,  a  drop 
of  carbolic  acid,  or  cocaine  solution  before  cauterizing. 

It  is  an  error  to  cauterize  every  chancroid  as  a  routine  measure, 
and  we  can  lay  it  down  as  a  rule  never  to  cauterize  unless  the  chancroid 
is  free  from  complications,  as  follows: — 

Contra-indications  for  Cauterization. — (a)  If  the  inflammation  is 
already  excessive  and  much  inflammatory  oedema  is  present,  the  irrita- 
tion of  cauterizing  will  increase  it. 

(h)  If  inguinal  adenitis  is  present,  the  bubo  will  be  made  worse 
by  cauterizing  the  chancroid. 

(c)  In  the  case  of  a  healing  cicatrizing  chancroid  the  chancroidal 
virus  has  already  disappeared,  and  cauterization  is  useless. 

{d)  If  a  numher  of  chancroids  are  present,  and  only  a  few  are  ex- 
posed, the  entire  number  should  be  destroyed,  or  none  at  all,  for  if  any 
are  left  untouched,  they  will  secrete  pus,  which  will  infect  fresh 
surfaces. 

(e)  If  a  chancroid  of  the  meatus  or  in  the  urethra  is  cauterized, 
the  resulting  cicatricial  contraction  after  the  sore  is  healed  will  pro- 
duce too  much  deformity  of  the  parts  affected. 

(b)   The  methodic  treatment  is  carried  out  by  means  of: — 

I.  Cleanliness. 

II.  Antisepsis. 

III.  Eest. 

The  chancroids  should  be  kept  free  from  the  accumulation  of 
discharge  by  means  of  frequent  washing  with  solutions  of  bichloride 
of  mercury,  1  in  5000  or  10,000;  or  carbolic  acid,  2  per  cent. 

Dry  dressings  or  dusting-powders  should  only  be  used  under  the 
foreskin  and  never  upon  a  sore  located  on  the  integument.  The  pow- 
der, which  is  exposed  to  the  air,  dries,  sticks  fast,  and  tears  open  the 
wound  when  the  dressing  is  changed. 

The  following  antiseptic  powders  are  the  most  serviceable:  Iodo- 
form, salicj'lic  acid  packed  into  the  sore,  aristol,  subgallate  of  bismuth 
(dermatol),  resorcin,  and  nosophen. 

"When  the  chancroid  is  located  upon  the  integument,  irei  dressings 
are  called  for.  A  piece  of  cotton  or  gauze  should  be  wet  with  bichlo- 
ride, carbolic,  or  Thiersch's  solution,  covered  with  a  piece  of  gutta- 
percha tissue  to  prevent  evaporation,  and  held  in  place  with  a  bandage. 


278 


CHANCROID  AND  ITS  COMPLICATIONS. 


COMPLICATIONS  OF  CHANCROID. 

The  accompanying  inflammation  may  at  times  become  excessive 
from  such  general  causes  as  debility  or  some  dyscrasia,  or  local  causes, 
such  as  contact  of  urine  or  lack  of  cleanliness.  An  excessive  inflam- 
mation, if  untreated,  is  apt  to  terminate  in  gangrene  and  sloughing  of 
the  parts. 

Subpreputial  Chancroids  Complicated  by  Phimosis. — When  chan- 
croids are  located  under  a  long  and  tight  foreskin,  the  resultant  swell- 
ing and  oedema  prevent  its  retraction,  and  render  the  diagnosis  diflfi- 
cult.  Artificial  inoculation  of  the  patient  upon  the  thigh,  with  pus 
from  under  the  foreskin,  has  been  resorted  to,  to  differentiate  between 
chancre  and  chancroid. 

The  possibility  of  the  presence  of  a  mixed  sore  should  always  be 
borne  in  mind  in  these  cases. 

TREATMENT. 
The  preputial  sac  may  be  kept  clean  by  the  use  of  antiseptic  in- 
jections with  a  flat-billed  syringe  under  the  foreskin,  using  a  weak 
carbolic  or  sublimate  solution  every  hour  or  two.    An  attempt  should 


Fig.  85. — Taylor's  Flat-Billed  Syringe  for  Washing  Out  the 
Balano-preputial  Sac. 


also  be  made  to  retract  the  foreskin  and  cauterize  the  sores,  which  can 
be  facilitated  by  prolonged  soaking  of  the  penis  in  hot  water. 

On  account  of  the  danger  of  paraphimosis,  the  foreskin  should 
not  be  left  retracted,  but  drawn  back  into  place. 

In  case  the  swelling  increases  and  surgical  interference  is  not 
resorted  to,  the  dorsum  of  the  prepuce  becomes  gangrenous  and 
sloughs  in  part,  or  the  entire  foreskin  sloughs  off  (spontaneous  circum- 
cision), or  the  glans  penis  becomes  gangrenous  and  sloughs,  either 
entirely  or  partially. 

If  gangrene  is  threatening,  recourse  must  be  had  at  once  to 
operative  measures.  The  prepuce  should  be  slit  up,  upon  the  dorsum, 
with  a  curved  bistoury,  to  relieve  the  tension. 


PHAGEDENA. 


279 


The  chancroids  are  exposed  and  cauterized,  and  in  addition  the 
entire  surface  of  the  fresh  cut  wound  is  caiiterized,  as  well,  with  either 
the  Paquelin  cautery  or  nitric  acid. 

Circumcision  should  never  be  performed  in  the  presence  of  chan- 
croids on  account  of  the  danger  of  infecting  the  wound  with  chan- 
croidal virus,  and  converting  its  entire  surface  into  a  chancroidal  ulcer. 

In  all  cases  of  subpreputial  chancroids,  if  at  all  severe,  the  radical 
treatment  of  slitting  up  the  foreskin  and  cauterizing  is  to  be  preferred 
to  temporizing  with  injections  under  the  foreskin. 

When  chancroid  of  the  frcenum  exists,  the  artery  is  liable  to  be 
ruptured  during  erection  and  haemorrhage  occurs.  To  prevent  this 
accident,  it  is  proper  to  tie  a  double  ligature  around  the  frsnum, 
divide  the  franum  between  the  ligatures  with  a  pair  of  scissors,  and 
cauterize  the  sore. 

Paraphimosis  is  the  condition  in  which  a  long  foreskin  is  retracted 
behind  the  glans,  and,  from  the  swelling  and  oedema  which  take  place 


Fig.  86.— Dorsal  Incision  through  Prepuce  to  expose  Chancroids. 

in  it,  is  prevented  from  being  drawn  back  into  place.  Gangrene  and 
sloughing  may  result,  if  the  condition  is  left  untreated.  The  con- 
stricting band  should  be  cut  upon  the  dorsum  by  inserting  a  curved 
bistoury  under  it  and  cutting  outward. 


PHAGEDENA. 

This,  most  formidable  of  all  the  complications  of  chancroid,  is 
rarely  encountered  at  the  present  day. 

It  is  due  to  debility  of  the  individual  attacked,  as  a  result  of  some 
dyscrasia,  alcoholism,  syphilis,  tuberculosis,  privation,  etc. 


280  CHANCROID  AND  ITS  COMPLICATIONS. 

Two  varieties  are  noted: — 

(a)  Serpiginous,  in  which  the  ulceration  creeps  slowly  along,  ad- 
vancing at  one  side.  It  is  a  very  chronic  condition,  and  may  last  for 
months. 

(b)  Sloughing,  in  which  the  parts  die  en  masse  in  a  short  time. 


TREATMENT. 

The  first  indication  is  to  treat  the  dyserasia,  by  means  of  tonics, 
of  which  the  potassio-tartrate  of  iron  in  5-grain  doses  every  three  hours 
is  highly  spoken  of,  quinine  in  tonic  doses,  and  opium  for  its  effect  on 
the  pain.  Easily-digested  nutritious  food  and  milk-punch  should  be 
administered. 

Locally  the  ulcerating  surface  should  be  cauterized,  with  the 
Paquelin  or  nitric  acid,  and  dressed  with  iodoform.  In  cases  which 
fail  to  respond  to  the  ordinary  treatment  hot  baths  are  valuable.  The 
body  is  immersed  for  days  and  weeks  at  a  time  in  a  tub  in  which  the 
water  is  kept  constantly  changing  and  at  the  same  temperature.  Un- 
der the  use  of  the  hot  water  the  sloughing  ceases  and  the  ulcers  take 
on  healthy  granulation. 


BUBO. 

The  term  bubo  is  applied  to  the  inflammatory  enlargement  of 
any  lymphatic  gland,  but  especially  in  the  inguinal  region. 

It  accompanies  chancroid  in  from  30  to  50  per  cent,  of  all  cases, 
and  is  particularly  liable  to  occur  in  debilitated  badly-nourished  sub- 
jects. 

ETIOLOGY. 

There  are  two  views  held  in  regard  to  the  causation  of  bul)o: — • 
(a)  It  is  believed  that  the  inflammation  of  the  lymphatic  glands 
is  caused  by  the  micro-organisms  from  the  chancroid,  which  are  carried 
to  the  glands  through  the  lymphatic  vessels  and  deposited  in  them. 

(Z>)  It  is  held  by  others  that  the  micro-organisms  themselves  are 
not  carried  to  the  glands,  but  only  certain  chemical  substances  (toxins), 
which  are  formed  in  the  chancroid  as  a  result  of  bacterial  growth  and 
deposited  in  the  adjacent  lymphatic  glands. 


BUBO. 


281 


COURSE. 

One  gland  alone  may  be  affected,  but,  as  a  rule,  the  whole  chain 
on  one  side  is  involved,  and  it  is  not  infrequent  for  several  glands  on 
both  sides  to  be  attacked. 

Exceptionally  the  involvement  may  disappear  by  resolution,  but 
in  the  great  majority  of  cases  the  glands  suppurate  and  break  down. 

The  process  of  softening  of  the  chain  of  glands,  and  their  break- 
ing down  and  suppuration,  and  the  slow  evacuation  of  the  pus  through 
a  small  opening,  is  a  very  protracted  one,  and  may  last  for  months 
unless  the  diseased  glands  are  completely  extirpated  by  surgical  meas- 
ures. 

The  accompanying  table  indicates  the  chief  points  of  difference 
between  the  glandular  enlargement  of  syphilis  and  that  of  fchan- 
croid: — 

DIFFERENTIAL  DIAGNOSIS  OF  BUBO  AND  SYPHILITIC  ADENOPATHY. 

Chanceoid.  Syphilis. 

One  side  affected,  as  a  rule.  Both  sides  affected. 

Shape:  Shape: 

Irregular  and  boggy.  Eegular,  smooth,  and  hard. 

Size:  Size: 

Large.  Small. 

Xiimher:  Nnmher: 

May  be  single.  Always  multiple   and   arranged   in   a 

chain. 

General  Characteristics:  General  Characteristics: 

Considerable  amount  of  inflammation,  No   inflammation.     Not   adherent   to 

causing  adherence  to  overlying  skin.  skin,  but  freely   movable.     Do  not 

Generally  suppurate.  suppurate. 


TREATMENT. 

The  indications  are: — 

I.  To  prevent  suppuration. 

II.  After  suppuration  has  taken  place  to  evacuate  the  pus  and 
extirpate  the  diseased  glandular  structures. 

To  prevent  suppuration,  the  most  important  measure  is  rest  in 
led,  supplemented  by  the  pressure  of  a  sand-bag  over  the  inflamed 
gland. 

Cold,  in  the  form  of  an  ice-bag  or  evaporating  lotion,  is  sometimes 
of  use.    Tincture  of  iodine  is  often  prescribed,  but  is  of  little  use  in 


282 


CHANCROID  AND  ITS  COiMPLICATIONS. 


assisting  resolution;  if  ordered  at  all,  it  should  not  be  painted  over  the 
inflamed  gland,  but  in  a  ring  around  it. 

Ichthyol  ointment,  50  per  cent.,  is  frequently  used,  but  is  of  less 
value  here  than  in  other  conditions. 

The  injection  of  antiseptic  solutions  into  the  substance  of  the 
gland  with  a  hypodermic  syringe,  using  carbolic  acid  (15  per  cent.) 
or  benzoate  of  mercury  (1  per  cent.)  is  a  rational  measure,  and  has 
attained  a  fair  degree  of  success  in  preventing  suppuration. 

The  various  measures  above  mentioned,  however,  rarely  succeed 
in  preventing  the  formation  of  pus,  and  on  that  account  it  is  better 
not  to  lose  valuable  time,  in  efforts  to  abort  the  suppuration,  which 
will  most  likely  prove  unavailing  in  the  end,  but  to  have  recourse 
proniptl_Y  to  surgical  measures. 

Operative  Treatment.  —  (a)  Before  Suppwation.  —  If  the  case 
comes  to  operation  before  the  glands  have  begun  to  suppurate,  a 
curved  incision  should  be  made  through  the  skin,  and  the  flap  turned 
back,  exposing  the  entire  chain  of  glands,  which  can  be  dissected 
out.  If  the  operation  is  done  before  the  formation  of  pus,  the  Avouud 
may  be  entirely  closed  by  sutures,  and  primary  union  usually  occurs. 

(h)  After  Suppuration. — When  the  glands  have  begun  to  sup- 
purate it  is  no  longer  possible  to  close  the  wound  entirely  by  suture, 
on  account  of  the  certainty  of  infection,  and,  instead  of  the  patient 
being  able  to  walk  about  in  a  week  with  the  wound  closed  by  primary 
union,  he  has  to  wait  from  four  to  six  weeks  for  the  slow  healing  by 
granulation  of  the  open  wound. 

The  indications  for  treatment  after  suppuration  has  occurred  are 
to  evacuate  the  pus,  by  a  free  incision,  and  at  the  same  time  remove 
completely  all  portions  of  the  glandular  structure,  by  means  of  careful 
dissection  or  the  sharp  curette.  The  wound  is  left  open  and  packed 
with  iodoform  gauze,  and  heals  by  granulation.  An  objection  to  ex- 
tirpating the  glands  before  they  have  entirely  broken  down  is  tbat, 
in  occasional  rare  instances,  a  permanent  oedema — resembling  ele- 
phantiasis— of  the  penis,  scrotum,  and  inguinal  region  follows,  in 
consequence  of  the  obliteration  of  the  lymphatic  vessels  in  the  process 
of  wound-healing.^  For  this  reason  Krulle  advises  the  applications 
of  hot  fomentations  till  the  gland  is  entirely  broken  down,  when  the 
pus  is  evacuated  through  a  small  incision.     Every  second   day  tbe 


'  Out  of  over  a  lumdred  cases  of  bubo  treated  by  dissecting  out  tlie  glands, 
the  author  has  only  seen  this  complication  occur  once. 


BUBO.  283 

piis  should  be  squeezed  out  and  the  cavity  of  the  wound  washed  with 
1-per-cent.  nitrate-of-silver  solution.  Under  this  treatment  the  pa- 
tient can  walk  about,  and  avoids  the  necessity  of  lying  in  bed.  This 
plan  may  work  successfully  when  the  glands  break  down  rapidly,  but 
in  many  instances  the  suppuration  goes  on  very  slowly,  and  it  is  better 
to  make  a  free  incision,  evacuate  the  pus,  and  dissect  or  curette  out 
the  partially  broken  down  remains  of  the  glands. 


SYPHILIS  AND  ITS  LESIONS. 


CHAPTER  XX. 

CHANCRE. 

Synonyms. — Initial  lesion  of  syphilis;  initial  sclerosis;  hard 
cliancre. 

Definition. — Chancre  may  be  defined  as  "the  first  manifestation 
of  the  syphilitic  poison  at  the  seat  of  its  entrance  into  the  body." 

The  poison  of  syphilis,  which  is  inoculated  into  an  individual  and 
causes  the  chancre,  is  derived  from  the  secretions  and  broken-down 
detritus  formed  in: — 

(a)  A  chancre  in  another  person. 

(b)  Mucous  patches. 

(c)  Condylomata. 

(d)  Blood. 

(e)  Lymph. 

(/)  It  was  formerly  thought  that  the  physiological  secretions  did 
not  contain  the  syphilitic  virus,  but  recent  investigations  have  shown 
that  in  exceptional  cases  they  do  contain  the  poison. 

COURSE. 

When  the  poison  of  syphilis  is  first  inoculated  under  the  skin,  it 
is  too  small  in  quantity  to  produce  any  symptoms.  But  the  poison 
increases  in  amount,  and,  after  three  or  four  weeks  have  passed,  the 
quantity  is  so  great  at  the  point  of  inoculation  that  the  tissues  react, 
and  the  chancre  appears. 

At  this  time  the  syphilitic  virus  is  not  distributed  all  through  the 
body,  but  is  localized  to  the  tissues  around  the  chancre  and  in  the 
nearest  lymphatic  glands.  Later  on  in  the  disease  the  poison  increases 
to  an  enormous  extent,  makes  its  way  through  the  lymphatic  system 
into  the  circulation,  and  the  blood  and  lymph  become  surcharged  with 
it. 

The  pus  from  a  chancre,  imlike  that  formed  in  a  chancroid,  has 
not  the  property  of  destroying  the  epidermis,  and  in  order  to  produce 
a  chancre  it  is  necessary  that  the  poison  from  a  syphilitic  lesion  be 
introduced  through  an  abraded  surface. 
(284) 


CHANCRE.  2gg 

This  fact  explains  the  cases  in  which  a  physician  attends  a  syph- 
ilitic woman  in  confinement  or  a  man  has  coitus  with  a  woman  who 
is  affected  with  condylomata  or  a  chancre,  and,  if  an  abrasion  did  not 
exist  at  the  time  of  contact,  inoculation  does  not  occur. 

Every  case  of  syphilis  contracted  after  birth  must  have  a  chancre 
for  its  point  of  departure. 

There  is,  however,  one  exception  to  this  rule.  A  healthy  woman 
who  has  connection  with  a  syphilitic  man  may  escape  inoculation  with 
syphilis,  but  become  pregnant.  The  child  which  is  generated  by  a 
syphilitic  father  is  infected  with  syphilis,  and  as  it  develops  in  utero 
the  syphilitic  virus  passes  from  the  child  to  the  mother  through  the 
placental  circulation,  and  in  turn  the  mother  becomes  infected  with 
syphilis  from  her  own  child.  In  this  case  chancre  does  not  form  either 
in  the  mother  or  child. 

The  form  of  infection  of  the  mother  just  described,  from  carry- 
ing her  own  child  in  utero,  is  called  "Choc  en  retour,"  or  "syphilis  by 
conception." 

TRANSMISSION  OF  CONTAGION. 

The  methods  by  which  the  contagion  is  transmitted  may  be 
classified  as: — 

(a)  Direct. 

(b)  Indirect,  or  mediate. 

(c)  Inheritance. 

(d)  Choc  en  retour,  or  syphilis  by  conception. 

By  direct  contagion  we  understand  those  methods  in  which  the 
syphilis  is  inoculated  by  personal  contact,  such  as  coitus,  kissing,  sur- 
gical operations,  a  syphilitic  child  infecting  its  wet-nurse,  or  a  healthy 
child  acquiring  syphilis  by  nursing  from  a  syphilitic  wet-nurse. 

In  indirect,  or  mediate,  contagion  the  disease  is  conveyed  through 
the  medium  of  some  article  which  has  been  infected  with  the  virus 
of  syphilis,  such  as  a  spoon,  pipe,  cup,  or  cigar  used  by  a  person  with 
mucous  patches  in  the  mouth;  an  instrument  used  for  tattooing, 
dental  or  surgical  operations,  which  had  been  used  on  a  syphilitic  in- 
dividual and  not  cleaned  afterward,  or  by  means  of  underclothing 
or  a  bathing-suit  which  was  stained  with  secretions  from  syphilitic 
lesions. 

Vaccination  chancre  in  former  years  was  not  uncommon,  and  was 
caused  by  vaccinating  with  an  instrument  which  had  previously  been 
used  to  vaccinate  a  syphilitic  individual,  and  which  was  not  afterward 
cleansed,  but  was  used  still  contaminated  with  the  syphilitic  virus. 


28g  SYPHILIS  AND  ITS  LESIONS. 

Chancres  were  also  produced  by  vaccinating,  with  dried  lymph- 
cnists,  which  had  been  taken  from  vaccine-vesicles  produced  in  an 
individual  who  was  also  affected  with  syphilis  at  the  same  time. 

At  the  present  day  animal  vaccine-lymph,  taken  from  the  calf, 
is  used  exclusively,  and,  as  cattle  are  immune  from  syphilis,  a  chancre 
as  the  result  of  vaccination  never  occurs. 

The  location  of  the  chancre  depends,  of  course,  upon  the  point 
at  which  the  syphilitic  virus  is  inoculated.  The  chancre  appears  most 
frequently  on  the  genitals,  but  may  be  on  the  lips,  tongue,  breast,  or 
fingers.  It  begins  as  a  papule  or  small  tumor,  which  increases  in  size; 
the  surface  becomes  eroded,  or  ulcerated,  and  furnishes  a  secretion 
which  is  not  autoinoculable.  The  most  characteristic  feature  of  the 
chancre  is  induration  of  the  base,  which  is  caused  by  a  deposit  of  small 
round  cells  in  the  tissues  underlying  the  chancre,  and  also  by  inflam- 
matory changes  in  the  blood-vessels. 


PATHOLOGY. 

On  microscopic  examination  of  a  chancre  the  findings  are  as 
follow : — 

I.  A  small  round-celled  infiltration  of  the  skin  and  subcutaneous 
tissues,  such  as  occurs  in  every  inflammation.  The  infiltration  begins 
in  the  blood-vessels  and  spreads  outward  toward  the  periphery.  For 
this  reason  the  form  of  the  induration  depends  upon  the  course  of 
the  blood-vessels.  When  they  run  horizontally  and  near  the  surface, 
a  thin,  flat  layer  of  infiltration  occurs  under  the  skin,  which  is  called 
parchment  induration.  On  the  other  hand,  when  the  blood-vessels 
dip  down  deeply  into  the  tissues,  the  induration  is  extensive  and  deep, 
and  is  called  Hunterian  induration. 

II.  Changes  in  the  Blood-vessels. — The  veins  and  arteries  are 
both  affected  by  the  endarteritis,  but  the  changes  are  more  marked 
in  the  arteries.  The  endothelial  cells  of  their  inner  coats  are  swollen 
and  the  lumen  of  the  vessel  is  diminished.  The  middle  coat  is  usu- 
ally slightly  thickened  and  infiltrated,  but  the  important  change  is  in 
the  outer  coat,  which  is  the  seat  of  an  infiltration  with  small  round 
cells. 

In  consequence  of  all  the  changes  described  the  circulation  of 
blood  is  shut  off,  and  coagulation-necrosis,  with  sloughing  of  small 
areas  of  tissue  supplied  by  the  affected  vessels,  takes  place. 

It  is  desirable  to  understand  clearly  the  pathological  changes, 


5#^ 


tw  ^^:.  "•■■   ■^^S'?^^"-' ■:' 


^J^^-.^S^|^;^^v^^:v^^;;|^P^ 


'^^^s^iri^vSj^o-'  ^^?;%. 


V.  Section  of  a  Chancre  (Injected). 


Rete  mucosum. 

Small  round-celled  infiltration  with  numerous  injected  blood-vessels. 

Blood-vessels  with  endo-  and  peri-  arteritis. 

Lymphatics  with  adventitial  and  endovascular  changes. 


f  \?r■i^H■•'''>^:  °  '^if^:_  -^v^^iv^^"^^'^;!^^ 


VI.  Section  tlirough  a  Papular  Sypliilifle. 

a,  ft,  c.  Small  round-celled  infiltration  through  corium  and  rete  mucosum 

and  around  hair-follicles  and  sweat-gland, 
d,  Blood-vessel,  with  infiltration  of  the  adventitia. 
C,   Normal  cutis. 


(From  ••  Die  Syphilis  und  die  Veuerisclien  Krankheiten."  vou  Dr.  Eruest  Finger.) 


CHANCRE. 


287 


since  all  syphilitic  lesions — including  chancre,  papule,  and  gumma — 
are  identical,  and  are  due  primarily  to  endarteritis,  and,  secondarily, 
to  the  accompanying  small  round-celled  infiltration. 

The  lymphatics,  as  a  rule,  are  not  affected,  but  remain  open  and 
serve  to  carry  the  virus,  to  be  deposited  in  the  neighboring  gland. 

In  rare  instances  an  endo-lymphangitis  occurs,  which  obstructs  the 
flow  of  lymph,  and  occasions  a  hard,  boggy  condition  of  the  tissues, 
causing  the  so-called  indurative  or  sclerotic  oedema. 

The  hardness  and  sclerosis  of  chancre  are  not  entirely  accounted 
for  by  the  microscopic  findings,  because  the  infiltrating  cells  are 
present  in  spots  where  no  trace  of  hardness  is  perceptible  to  the  touch. 

Unna  attempts  to  account  for  the  hardness  by  supposing  that  a 
deposit  of  colloid  material  takes  place  around  and  between  the  bands 
of  round-celled  infiltration  in  the  older  parts,  but  that  it  is  not  formed 
as  rapidly  as  the  infiltration  advances  at  the  periphery. 

The  essential  characteristics  are  always  the  same,  but  chancres 
vary  considerably  in  outward  appearances,  as,  for  example: — 

(a)  In  the  amount  of  induration. 

(b)  In  the  depth  of  ulceration. 

(c)  In  the  amount  of  inflammation  of  the  surrounding  tissues. 
Therefore  chancre  is  grouped  into  several  varieties. 


VARIETIES. 

I.  Dry  papule,  which  is  made  up  of  a  very  slight  amount  of 
induration. 

II.  Hunterian  chancre.  In  this  variety,  which  is  named  after 
John  Hunter,  a  considerable  amount  of  induration  is  present.  Its 
central  part  is  the  seat  of  a  coagulation-necrosis,  from  the  endarteritis 
which  occludes  the  blood-vessels  and  causes  a  depression  in  the  centre, 
which  is  funnel-shaped,  or  like  the  crater  of  a  volcano.  The  Hun- 
terian chancre  is  the  form  most  commonly  met  with. 

III.  Parchment  chancre.  This  form  is  due  to  a  superficial  layer 
of  infiltration  lying  immediately  under  the  skin  and  widely  spread 
out  in  the  tissues.  It  feels  like  a  piece  of  parchment  on  being  pinched 
up  between  the  fingers. 

IV.  Indurative  or  sclerotic  oedema.  This  condition  is  produced 
by  a  combination  of  the  usual  endarteritis  and  small  round-celled 
infiltration,  and  in  addition  it  is  accompanied  by  an  inflammation  of 
the  lymphatic  vessels  or  endo-lymphangitis. 


288  SYPHILIS  AND  ITS  LESIONS. 

The  circulation  of  the  lymph  is  interfered  with,  and  it  transudes 
from  the  lymphatic  vessels  into  the  tissues.  This  combination  of 
pathological  changes  gives  rise  to  a  boggy  condition  of  the  tissues, 
which  is  harder  and  more  pronounced  than  in  simple  oedema,  and,  on 
being  pinched  between  a  finger  and  thumb,  a  condition  of  fibrosis  is 
felt.  Indurative  oedema  is  a  rare  condition,  but  occurs  more  frequently 
on  the  female  genitals  than  in  men. 

CHANCRE  HEALS  WITHOUT  LEAVING  A  SCAR. 

The  ulceration  and  necrosis  of  the  chancre  take  place  at  the  ex- 
pense of  the  newly-formed  tissue-elements  rather  than  the  normal 
structures  of  the  parts  affected,  and  consequently  no  scar  results. 
Chancroids  always  leave  a  scar  after  healing,  because  the  ulceration 
spreads  and  destroys  normal  fixed  cells  of  the  part. 

DURATION  OF  THE  CHANCRE. 

A  chancre  may  heal  in  a  few  days  or  may  remain  unhealed  for 
many  months,  especially  if  it  is  located  under  the  prepuce,  and  pro- 
vided no  mercurial  treatment  is  given. 


CHANCRE  OF  THE  URETHRA. 

Chancre  located  ivitliin  the  urethra  is  a  rare  condition,  but  it  does 
occur  at  times.  It  is  usually  located  from  one-half  to  one  inch  from 
the  meatus,  and  the  only  symptom  which  it  occasions  is  a  thin  dis- 
charge from  the  urethra,  which  may  be  easily  mistaken  for  a  gonor- 
rhoea. Examination,  however,  shows  a  hard,  sclerotic  mass  surround- 
ing the  urethra  under  the  skin,  and  the  nearest  lymphatic  glands  are 
also  enlarged. 

A  knowledge  of  the  fact  that  a  chancre  may  be  concealed  within 
the  urethra  will  sometimes  be  of  service  in  explaining  the  cases  of 
syphilis  in  which  the  patient  admits  having  had  a  slight  gonorrhoea, 
but  who  denies  that  he  ever  had  a  chancre.  In  these  instances  the 
discharge  from  the  chancre,  issuing  from  the  meatus,  was  mistaken 
for  a  urethritis. 

DIAGNOSIS. 

We  should  always  avoid  haste,  in  making  a  diagnosis  of  chancre, 
anrl.  if  any  doubt  exists,  we  should  await  the  development  of  secondary 
symptoms. 


CHANCRE. 


289 


In  the  case  of  a  sore  occurring  a  few  days  after  coitus  it  is  often 
impossible  to  exclude  syphilis  until  at  least  three  weeks  have  elapsed, 
on  account  of  the  possibility  of  a  mixed  infection  having  occurred. 

When  in  doubt  as  to  the  diagnosis,  we  can  wait  for  secondary 
symptoms — i.e.,  eruption,  mucous  patches,  alopecia,  fever,  and  head- 
ache— to  confirm  it,  or  we  can  make  the  diagnosis  by  confrontation. 

Diagnosis  by  confrontation  is  made  by  examining  the  individual 
from  whom  the  patient  acquired  the  sore,  in  order  to  determine  the 
presence  or  absence  of  syphilis. 

The  most  reliabh  diagnostic  points  of  chancre  may  be  summarized 
as  follows: — 

I.  Indolent  painless  swelling  of  the  nearest  lymphatic  glands, 
which  are  polyganglionie:  i.e.,  arranged  in  a  chain. 

II.  Induration  of  the  base  of  the  sore,  which  consists  of  a  hard, 
cartilaginous  induration,  and  feels  like  a  foreign  body  imbedded  in 
the  tissues. 

III.  History  of  the  period  of  incubation,  lasting  about  three 
weeks. 


DIFFERENTIAL  DIAGNOSIS  BETWEEN  CHANCRE  AND 
CHANCROID. 

Chancke.  Chancroid. 

Incubation:  Incuhation: 

Three  Aveeks.  Is' one. 

Commencement:  Commencement: 

Begins   as   erosion    or   papule,    -wliich  Pustule  or  ulcer,  and  remains  so. 
undergoes  superficial  ulceration. 

tfnmhers:  Numhers: 

Single  generally.    If  multiple,  so  from  Multiple  from  beginning  or  became  so 

beo-innino'.  by  autoinoculation. 

Edges:  Edges: 

Level  or  sloping  and  adherent,  giving  Abrupt  and  undermined, 
"scooped-out  appearance." 

Floor:  Floor: 

Smooth,  shining,  red,  or  raw;    covered  Rough;    worm-eaten;    "wash  leather" 

with  slight  deposit.  in  appearance. 

Secretion:  Secretion: 

Scanty;    slightly  purulent;'  not  auto-  Abundant   and   purulent;     autoinocu- 

inoculable.  lable. 

Progress:  Progress: 

Slow.  Rapid. 


290  SYPHILIS  AND  ITS  LESIONS. 

Chancre.  Chancroid. 

Induration:  I  ud  unit  ion: 

Constantly  present.  None  or  boggy. 

P(tin:  Pain: 

Absent.  Present. 

Bubo:  Bubo: 

Constantly  present.     (See  table  in  sec-       Occurs  in  1  out  of  3  cases, 
tion  on  "Bubo.") 

Scar:  Scar: 

Heals  without  scar.  Scar  always  remains. 

PROGNOSIS. 

It  may  be  stated,  in  a  general  way,  that  the  severity  of  the  chancre 
bears  some  relation  to  the  gravity  of  the  secondary  manifestations. 
When  the  chancre  is  benign,  it  is  probable  that  the  secondary  lesions 
will  be  superficial  and  of  a  mild  type,  which  can  be  explained  in  the 
following  way:  In  a  debilitated  individual  the  tissues  react  more  vio- 
lently to  the  syphilitic  poison,  and  consequently  both  chancre  and 
secondaries  are  more  severe,  while,  on  the  other  hand,  the  tissues  of 
a  vigorous,  well-nourished  person  are  in  a  better  condition  to  resist 
the  action  of  the  poison. 

The  type  of  chancre,  however,  is  no  indication  as  to  the  severity 
of  tertiary  lesions,  and  the  severest  tertiary  accidents  often  follow  a 
mild  chancre. 

This  is  sometimes,  no  doubt,  due  to  the  fact  that  treatment  is 
often  neglected  or  insufficient  in  mild  cases. 

TREATMENT  OF  CHANCRE. 

The  cardinal  rule  in  the  treatment  of  chancre  is  to  avoid  every 
form  of  irritation;  caustics,  strong  applications,  or  mechanical  irri- 
tants should  never  be  used. 

When  the  chancre  is  located  on  the  integument,  a  moist  dressing 
should  be  used,  consisting  of  a  piece  of  cotton  or  gauze,  soaked  in 
bichloride  solution  (1  in  2000),  extract  of  hamamelis,  Listerine, 
Thiersch's  fluid,  or  black  wash,  and  covered  with  a  piece  of  gutta- 
percha tissue  to  prevent  evaporation. 

If  the  chancre  is  located  beneath  the  prepuce,  a  simple  dusting- 
powder  of  calomel,  dermatol,  iodoform,  or  aristol,  which  is  covered 
with  cotton,  forms  a  suitable  dressing  that  absorbs  the  discharge  and 
prevents  the  open  sore  from  being  infected  with  pus-organisms. 


ABORTION  OF  SYPHILIS  AFTER  INFECTION.  291 

Mercurial  plaster  is  a  useful  application  to  the  chancre  in  any 
location,  and  the  local  contact  of  the  mercury  with  the  chancre  in- 
duces a  certain  amount  of  absorption. 


ABORTION  OF  SYPHILIS  AFTER  INFECTION. 

It  is  commonly  held  to-day  among  syphilographers  that  it  is 
better  to  avoid  giving  mercury  internally  until  the  secondary  symp- 
toms of  syphilis  appear.  It  is  impossible  to  abort  the  syphilis  by  the 
premature  use  of  mercury,  and  the  appearance  of  the  eruption  is  only 
retarded. 

It  is  believed  by  Ehrmann  and  others  that  the  patient  is  rendered 
more  liable  to  tertiary  affections  if  mercury  is  given  before  the  erup- 
tion appears,  and,  while  it  is  true  that  its  internal  administration 
causes  the  rapid  absorption  and  disappearance  of  the  chancre,  if  used 
too  early  in  the  disease,  it  is  detrimental,  in  the  long  run,  to  the 
patient. 

The  early  excision  of  the  chancre,  before  the  appearance  of  the 
secondary  symptoms,  was  widely  recommended  and  practiced  a  few 
years  ago,  upon  the  ground  that  the  virus  was  strictly  localized  to  the 
chancre  and  the  tissues  in  its  immediate  vicinity,  and  that  the  poison 
might  be  entirely  removed  from  the  body  by  excising  the  sore.  A 
more  extended  experience  has  shown  this  to  be  fallacious,  and  to-day 
the  procedure  is  regarded  as  useless. 


CHAPTER    XXI. 

SYPHILIS. 

Syphilis  may  be  defined  as  a.  chronic  infectious  disease,  due  to 
a  specific  poison,  probably  a  micro-organism.  Its  local  manifestations 
are,  primarily,  inflammatory  changes,  beginning  in  the  coats  of  the 
blood-vessels  and  involving  the  perivascular  tissues.  After  two  or 
three  years  its  contagious  element  disappears,  and  the  disease  assumes 
the  nature  of  a  diathesis. 

THE  VIRUS. 
The  virus,  or  poison,  of  syphilis  is,  in  all  probability,  a  micro- 
organism belonging  to  the  class  of  schistomyceten,  although  it  has 
not  3^et  been  demonstrated  with  certainty.  The  proof  tests,  which 
bacteriologists  insist  upon,  of  isolation  of  the  bacillus,  its  cultivation, 
and  the  subsequent  production  of  the  parent-disease  by  inoculation  of 
the  cultivated  organism  into  a  healthy  animal,  have  not  as  yet  verified 
the  existence  of  the  specific  organism. 


CARRIERS  OF  THE  POISON. 

The  virus  of  syphilis  is  contained  in  the  secretions,  which  are 
derived  from  the  lesions  of  the  primary  and  secondary  stages,  and  in 
the  blood,  lymph,  and  semen. 

Recent  investigations  have  also  shown  that  the  ph3'siological  se- 
cretions of  glands — i.e.,  the  milk,  tears,  and  saliva — do,  at  times,  but 
only  exceptionally,  contain  the  poison.  It  is  of  frequent  occurrence, 
however,  for  the  saliva  and  milk  to  be  contaminated  or  mixed  with 
the  discharges  from  mucous  patches  from  the  mouth  or  nipple. 

Syphilis  loses  its  contagious  quality  in  the  tertiary  stage,  and  the 
blood  and  secretions  from  lesions  are  no  longer  capable  of  conveying 
the  disease. 


ANALOGY  BETWEEN  SYPHILIS  AND  THE  ERUPTIVE  FEVERS. 

A  distinct  parallel,  which  has  been  pointed  out  by  Jonathan 
Hutchinson,  exists  in  the  course  of  syphilis  and  small-pox,  measles, 
scarlatina,  etc.  All  these  diseases  are  due  to  a  special  and  distinct 
(292) 


SYPHILIS. 


293 


poison,  which  is  introduced  into  the  body.  After  a  period  of  incuba- 
tion, during  which  the  virus  increases  in  volume,  its  quantity  becomes 
so  great  that  the  organism  is  saturated  with  it,  and  constitutional 
symptoms  occur.  Each  disease  runs  its  own  definite  and  self-limited 
course,  and  afterward  a  condition  of  immunity  follows,  which  lasts  for 
years,  or  often  for  the  remainder  of  the  life  of  the  individual. 


INOCULATION  AND  COURSE  OF  SYPHILIS. 

After  inoculation  with  the  virus  of  syphilis  no  symptoms  are 
observed  at  the  point  of  entrance  or  elsewhere  for  a  period  of  at  least 
three  weeks. 

It  is  supposed  that  at  this  time  the  micro-organisms  are  too  few 
in  number  to  cause  any  reaction  of  the  tissues,  but,  as  they  increase 
in  number,  they  induce  a  condition  of  local  irritation,  and  the  chancre 
appears.  The  virus  continues  to  increase,  is  taken  up  by  the  lymphatic 
vessels  and  carried  to  the  nearest  lymphatic  glands,  which  serve  as 
incubating  places  for  the  micro-organisms.  The  glands  undergo  en- 
largement successively,  and  ultimately  the  virus  reaches  the  general 
blood-circulation. 

When  saturation  of  the  blood  has  occurred,  the  fact  is  announced 
by  prodromata,  which  are  soon  followed  by  an  eruption  on  the  skin 
and  mucous  membranes,  and  later  the  eye,  periosteum,  and  viscera  are 
attacked  by  inflammatory  changes,  consisting  in  arteritis  and  small 
round-celled  infiltration. 

The  eruption  remains  upon  the  skin  for  from  four  to  six  weeks 
ordinarily,  and  then  disappears,  and  for  a  time  no  S3'mptoms  of  the 
disease  are  present.  This  interval  in  the  manifestation  is  spoken  of 
as  a  period  of  latency. 

It  is  supposed  that  the  poison  which  had  been  circulating  in  the 
blood  was  either  eliminated  or  neutralized  by  the  antitoxin  formed  in 
the  body,  but  that  a  certain  quantity  of  virus  still  remained  stored 
up  in  the  lymphatic  glands.  As  this  stored-up  virus  increases  in  quan- 
tity, fresh  discharges  of  it  are  thrown  into  the  blood-current,  satura- 
tion again  takes  place,  and  a  relapse  occurs. 

Eelapses  followed  by  periods  of  latency  occur  at  intervals  of 
from  three  to  six  months  during  the  entire  course  of  the  disease, 
and  it  is  noted  that  relapses  are  more  apt  to  take  place  in  patients 
who  have  had  little  or  no  treatment. 

In  the  majority  of  cases  which  receive  systematic  and  adequate 


294  SYPHILIS  AND  ITS  LESIONS. 

treatment  relapses  cease  after  from  one  to  three  years.  But  it  does 
not  necessarily  follow  that  the  syphilis  is  at  an  end  because  a  con- 
siderable length  of  time  passes  without  a  relapse.  After  a  period  of 
latency,  which  may  extend  over  many  years,  new  symptoms  may 
again  develop. 

The  late  lesions  differ  from  the  early  ones  in  that  they  are  of  a 
grave  nature  and  do  not  tend  to  spontaneous  recovery,  but  are  more 
apt  to  destroy  the  organs  attacked.  The  secretion  which  they  furnish 
has  also  lost  its  contagious  properties. 

MODE  OF  INCREASE  OF  THE  VIRUS. 

After  reaching  the  blood-current  the  virus  has  the  property  of 
passing  through  the  walls  of  the  blood-vessels  by  osmosis,  and  is 
deposited  at  various  points  in  the  tissues.  Wherever  the  virus  is 
deposited  local  inflammatory  infiltration  occurs. 

As  the  virus  is  in  these  various  spots,  their  secretions  and  detritus 
can  produce  syphilis  if  inoculated  into  another  individual.  As  a  con- 
sequence of  the  growth  and  activity  of  the  bacteria  which  we  assume 
to  be  the  cause  of  syphilis,  and  which  are  believed  to  increase  and 
multiply  in  the  chancre,  lymphatic  glands,  and  all  secondary  lesions, 
toxins  are  produced  which  have  a  poisonous  effect  upon  the  nervous 
system,  and  occasion  fever,  headache,  and  backache. 

STAGES  OF  SYPHILIS. 

It  is  found  convenient  to  divide  the  regular  course  of  syphilis  into 
three  stages,  as  follows: — 

I.  Primary  stage,  which  includes  the  time  from  the  moment  of 
infection  to  the  outbreak  of  general  symptoms  (eruption  and  mucous 
patches,  etc.),  and  which  lasts  from  eight  to  ten  weeks. 

For  the  first  three  weeks  of  the  primary  stage  there  are  no  symp- 
toms to  indicate  that  the  individual  contains  the  virus  of  syphilis  in 
his  tissues.  At  the  end  of  three  weeks  the  chancre  appears,  and  the 
adjacent  glands  become  enlarged  and  are  the  only  signs  of  infection. 

II.  The  secondary  stage  begins  when  the  eruption,  alopecia,  and 
mucous  patches  make  their  appearance.  It  is  the  stage  of  typical  and 
regular  development  of  eruptions  and  their  accompanying  symptoms, 
and  periods  of  latency  alternate  with  relapses.  The  secondary  stage 
lasts  from  six  to  eighteen  months,  or  about  one  year  on  the  average. 

III.  The  tertiary  stage  comes  on  after  a  prolonged  period  of 


SYPHILIS. 


295 


latency,  and  is  the  stage  of  formation  of  gumma.  The  tertiary  stage 
may  never  occur.  Its  secretions  are  not  contagious,  and  it  resembles 
a  diathesis  more  than  an  active  disease. 


INCUBATION, 

Definition. — The  period  of  time  which  elapses  after  the  poison 
has  entered  the  body  and  until  the  first  manifestation  of  its  working 
appears.  The  poison  is  not  inactive  during  this  time,  but  increasing 
in  quantity. 

The  primary  stage  of  syphilis  is  divided  into  two  periods  of  in- 
cubation:— 

(a)  P&riod  of  primary  incubation,  which  is  the  period  from  the 
time  of  infection  until  the  chancre  appears.  The  chancre  represents 
the  reaction  of  the  tissues  in  consequence  of  the  local  increase  of  the 
virus. 

(b)  Period  of  Secondary  Incubation. — This  is  the  time  from  the 
appearance  of  the  chancre  imtil  the  eruption  is  seen.  The  eruption 
indicates  that  the  blood  is  saturated  with  the  virus. 


GIANDULAR  ENLARGEMENT. 

The  lymphatic  glands  are  supposed  to  act  as  places  for  the  in- 
cubation, growth,  and  development  of  the  syphilitic  virus  and  to  serve 
as  store-houses  for  it,  during  the  entire  secondary  stage.  The  glands 
nearest  the  chancre  begin  to  enlarge  about  four  weeks  after  infection. 

General  Characteristics. — The  glands  become: — 

(a)  Firm  and  hard. 

(b)  Freely  movable  under  the  skin. 

(c)  No  pain. 

(d)  Earely  suppurate  except  in  strumous  or  weak  patients. 

The  glands  nearest  the  chancre  become  enlarged  first;  conse- 
quently we  find  that,  when  the  chancre  is  located  on  the  penis,  the 
inguinal  glands  enlarge  first;  when  the  seat  of  the  chancre  is  on  the 
breast,  the  ancillary  glands  are  the  first  to  become  affected;  and,  if  the 
chancre  is  located  on  the  tongue  or  lips,  the  submaxillary  glands  are 
first  attacked. 

The  lymphatic  vessels  l3dng  between  the  glands  often  become 
hard  and  indurated,  feeling  like  cords,  and  this  condition  is  called 
lympliangitis. 


296  SYPHILIS  AND  ITS  LESIONS. 

Course  of  Virus  Through  the  Lymphatic  System. — The  syphilitic 
virus  pursues  the  following  course,  in  its  progress  through  the  lym- 
phatic vessels  into  the  general  blood-circulation: — 

The  small  round-celled  infiltration,  which  occurs  in  the  chancre, 
closes  up  the  mouth  of  the  blood-vessels  and  temporarily  holds  in 
check  the  spread  of  the  poison.  The  multiple  swelling  of  the  lym- 
phatic glands  also  retards  the  entrance  of  the  virus  into  the  blood- 
current. 

After  the  virus  begins  its  increase  in  the  chancre,  a  part  of  it  is 
carried  to  the  nearest  lymphatic  gland,  which  is  a  favorable  spot  for 
its  growth  and  increase.  Part  of  the  virus  which  is  deposited  here 
remains  and  a  part  travels  farther  to  the  next  lymphatic  gland. 

When  the  chancre  is  located  on  the  penis,  the  course  of  the  virus 
is  as  follows:  Through  the  inguinal  glands,  lymphatic  glands  in  the 
abdominal  cavity,  receptaculum  chyli,  and  thoracic  duct,  from  which 
it  is  poured  into  the  left  subclavian  vein  and  general  blood-circulation. 

During  this  time  the  cervical  and  axillary  glands  have  had  none 
of  the  virus  passing  through  them.  After  the  blood  has  become 
charged  with  the  virus,  they  filter  out  the  poison,  are  infected,  and 
become  enlarged  in  consequence. 


SECONDARY  SYPHILIS. 
PRODROMAL  SYMPTOMS,  OR  PRODROMATA. 

The  virus  of  syphilis  has  the  power  of  destroying  the  red  corpus- 
cles after  it  has  entered  the  blood-circulation,  and  on  microscopic 
examination  we  find  that  the  red  corpuscles  are  diminished  in  number, 
with  a  decrease  of  haemoglobin,  and  that  the  number  of  leucocytes  is 
increased.  In  consequence  of  these  changes  the  skin  and  mucous 
membranes  appear  pale  and  ancemic. 

Fever  is  present  in  nearly  every  case.  It  is  usually  slight  in  well- 
nourished  and  strong  individuals,  but  in  debilitated  subjects  may  reach 
103°  or  104°  F. 

Nocturnal  Pains. — The  shafts  of  the  long  bones,  such  as  the  tibia 
and  ribs,  and  the  vertex  of  the  cranium  are  usually  affected  with  pains 
which  are  more  or  less  severe,  and  which  have  the  peculiarity  of 
remitting  through  the  day  and  coining  on  at  night,  and  reach  their 
maximum  intensity  about  midnight. 


f 


n 

0 

-.  a 

1  ^ 

> 

J  - 

1     D 


SECONDARY  SYPHILIS.  297 

The  pains  are  boring  or  tearing  in  character,  and  are  called 
osteocopic  pains  (bone-tearing). 

Jaundice  occurs  in  a  small  proportion  of  cases,  and,  while  its 
cause  is  not  definitely  ascertained,  it  is  assumed  to  be  due  to  either 
(a)  pressure  upon  the  common  bile-duct,  from  the  enlarged  lymphatic 
glands  lying  in  the  abdomen,  or  (&)  from  congestion  and  swelling  of 
the  mucous  membrane  lining  the  common  bile-duct,  as  a  result  of  the 
disturbed  circulation. 

Albuminuria  occurs  occasionally.  It  is  temporary  in  character 
and  is  due  to  congestion  of  the  kidneys. 

Erythema  of  the  fauces  is  a  most  constant  symptom,  and  appears 
as  a  generally  diffused  erythematous  redness  upon  the  pillars  of  the 
fauces  and  the  pharynx. 

All  the  symptoms  described  above  under  the  term  prodromaia 
appear  before  the  eruption  and  mucous  patches,  and  are  all  occasioned 
by  a  disturbance  in  the  local  blood-supply,  which  induces  a  condition 
of  hyperemia  or  active  congestion  in  the  various  organs  affected. 


The  mucous  patch  is  one  of  the  most  constant  and  characteristic 
lesions  of  secondary  syphilis.  It  makes  its  appearance  about  the  same 
time  that  the  eruption  is  observed.  In  the  earliest  stage  the  mucous 
patch  appears  as  a  pearly-white  round  spot  upon  the  mucous  mem- 
brane of  the  mouth,  entrance  to  the  vagina,  margin  of  the  anus,  or 
under  the  female  breast.  Its  development  may  occur  wherever  the 
skin  is  thin  and  delicate  and  kept  macerated  by  secretions. ' 

As  it  is  seen  first,  the  mucous  patch  looks  as  though  nitrate  of 
silver  had  been  brushed  over  the  surface.  After  a  little  time,  the 
infiltrated  pellicle  of  mucous  membrane  sloughs  off,  leaving  a  shallow, 
sharply-defined,  "punched-out-looking"  ulcer.  This  might  be  re- 
garded as  the  second  stage  of  the  process,  and  is  the  form  in  which 
the  mucous  patch  is  most  commonly  seen. 

The  condyloma  may  be  looked  upon  as  the  third  stage  in  the 
development  of  the  mucous  patch,  and  is  brought  about  by  the  active 
growth  and  proliferation  upon  the  floor  of  the  ulcer.  The  result  is 
the  formation  of  cauliflower-like  granulations,  which  rise  in  little 
hillocks,  above  the  level  of  the  surrounding  healthy  skin. 

The  secretion  which  is  very  abundantly  furnished  by  mucous 


298  SYPHILIS  AND  ITS  LESIONS. 

patches  and  condylomata  is  highly  contagious,  and  is  responsible  for 
the  transmission  of  most  of  the  cases  of  syphilis. 


ALOPECIA. 

In  many  cases  of  early  secondary  syphilis,  although  not  invari- 
ably, the  hair  falls  out  to  a  greater  or  less  degree. 

It  is  due  to  two  different  causes: — 

(a)  The  impaired  quality  of  the  blood  fails  to  afford  sufficient 
nourishment  for  the  hair-bulbs,  and  they  die. 

(h)  An  increased  secretion  of  sebum  takes  place  around  the  bulb, 
and  by  its  pressure  shuts  off  the  circulation  of  the  nutrient  fluid  in 
the  shaft  of  the  hair. 

Alopecia  occurs  in  various  forms.  It  may  be  complete,  in  which 
case  the  hair  of  the  head,  eyebrows,  and  pubes  may  fall  out  entirely. 
The  usual  form,  however,  consists  in  a  patchy  baldness,  the  hair  fall- 
ing out  in  small  patches  of  the  size  of  a  finger-nail.  In  some  cases 
there  is  only  a  general  thinning  of  the  hair,  without  the  formation 
of  any  distinct  bald  patches. 

The  prognosis  is  good,  and  the  hair  always  grows  in  again,  unless 
an  ulcerative  process  has  taken  place  upon  the  scalp  and  destroyed  the 
hair-follicles. 


SKIN  ERUPTIONS,  OR  SYPHILIDES. 

The  appearance  of  the  rash  upon  the  skin  announces  that  the 
blood  is  saturated  with  the  virus  of  syphilis.  The  eruption  is  sup- 
posed to  be  caused  primarily  by  the  irritating  effect  of  the  virus  upon 
the  vasomotor  centres,  causing  a  local  paralysis  and  temporary  dilata- 
tion of  the  arterioles  in  the  skin,  with  inflammatory  changes  within 
and  around  the  vessel,  at  the  spot  where  each  lesion  is  located. 

Microscopically  all  the  eruptions  of  syphilis  are  identical,  and 
vary  in  outward  appearances  only  because  of  the  difference  in  the 
amount  of  cellular  infiltration.  , 

On  microscopic  examination  all  the  lesions  are  found  to  be  due  ! 
to  two  distinct  morbid  processes: — 


SKIN  ERUPTIONS,  OR  SYPHILIDES. 


299 


(a)  Inflammation  in  the  outer  and  inner  coats  of  the  arterioles, 
accompanied  by  stasis  of  blood  or  hyperemia  in  the  capillaries. 

(b)  An  infiltration  of  small  round  cells,  as  the  result  of  the  in- 
flammatory process,  which  begins  in  the  arterioles  and  spreads  out- 
ward toward  the  periphery,  in  the  tissues  surrounding  the  vessels.  At 
times  the  changes  of  arteritis  and  cellular  infiltration  are  so  great  that 
the  circulation  of  blood  through  the  vessels  is  cut  off,  and  the  parts 
supplied  become  the  seat  of  coagulation-necrosis  and  slough  out. 

Classification  and  Anatomy  of  Eruptions  Occurring  in  the  Sec- 
ondary Period.  ^ — /.  Macular  Stjphilide.  Synonyms:  Syphilitic  ery- 
thema;  S3'philitic  roseola. 

The  pathological  change  in  the  skin  which  is  the  seat  of  a  macular 
syphilide  consists  in  periarteritis  and  endarteritis,  with  an  excess  of 
blood  in  the  capillaries;  but,  while  the  round-celled  infiltration  has 
taken  place  in  the  tissues,  it  is  so  slight  in  amount  that  it  can  only 
be  detected  by  microscopic  examination. 

AVhen  a  considerable  amount  of  round-celled  infiltration  has  been 
produced,  it  is  readily  perceptible,  and  forms  nodules  or  small  tumors, 
which  are  spoken  of  as  the 

//.  Papular  Syphilide.  —  The  papules  forming  this  variety  of 
syphilide  may  be  as  large  as  a  10-cent  piece  or  as  small  as  a  pin's 
head,  and  are  accordingly  classified  as  the  large  or  small  papuLur 
syphilide. 

In  certain  cases  the  epidermis  covering  the  papule  scales  off,  but 
remains  partly  attached,  and  the  syphilide  is  then  spoken  of  as  papulo- 
squamous. 

If  the  centre  of  the  papule  becomes  necrotic  and  breaks  down,  a 
funnel-shaped  depression  is  formed,  which  is  filled  with  pus  and  cov- 
ered over  by  a  scale  of  epidermal  covering.  This  variety  is  known  as 
the  papulo-puslular  syphilide. 

III.  The  Pustular  Syphilide. — The  pustular  syphilide  is  formed 
from  a  pre-existing  papule  whose  central  part  undergoes  necrosis  and, 
as  a  result  of  obliteration  of  the  arterioles  from  endarteritis  and  peri- 
arteritis, sloughs  and  breaks  down.  The  process  is  then  complicated 
by  the  inoculation  of  pyogenic  micro-organisms.  These  cause  a  sup- 
puration of  the  central  part  of  the  papule,  and  the  accumulation  of 
pus,  which  forms  underneath  a  covering  of  epidermis,  which  is  raised 
up  above  it,  preventing  its  escape. 

IV.  The  Pigmentary  St/philide.— This  form  of  syphilide  should 


300  SYPHILIS  AND  ITS  LESIONS. 

not  be  confounded  with  the  pigmentation  which  remains  after  the  dis- 
appearance by  absorption  of  a  papule. 

The  pigmentary  syphilide  occurs  as  an  independent  eruption  upon 
a  spot  which  was  not  previously  affected.  It  is  occasioned  by  the 
endarteritis  and  periarteritis,  which  allows  the  red  corpuscles  of  the 
blood  to  escape  through  the  vessel-walls  into  the  tissues.  The  hnemo- 
globin  of  the  escaped  blood  becomes  dark  brown  in  color,  occasioning 
a  pigmented  appearance  of  the  skin,  and  is  ultimately  absorbed,  leav- 
ing the  skin  whiter  in  appearance  than  before. 

The  pigmentary  syphilide  occurs  in  two  forms'. — 

(a)  As  dark  spots  or  patches  of  brown  pigmented  skin. 

(&)  As  a  diffuse,  wide-spread,  dark  pigmentation,  with  areas  of 
healthy  white  skin  scattered  here  and  there  through  it.  In  this  form 
ih)  absorption  of  the  haemoglobin  has  taken  place  in  certain  areas  of 
the  pigmented  patch,  leaving  white  spots  free  from  pigment. 

Distribution  of  Syphilides  over  the  Body. — The  portion  of  the 
skin  attacked  and  the  extent  of  the  eruption  depend  upon  the  age 
of  the  S3'philis. 

The  early  eruptions  which  occur  during  the  first  six  months  are: — 

(a)  Superficially  seated  in  the  skin. 

(b)  Generally  distributed  over  the  body,  appearing  first  upon  the 
chest  and  abdomen  and  spreading  subsequently  to  the  palms  and  soles. 

(c)  The  eruption  is  symmetrical,  occurring  alike  on  both  sides  of 
the  body,  and  tends  to  arrange  itself  along  the  course  of  the  con- 
nective-tissue bundles  which  lie  under  the  skin  (called  lines  of  cleav- 
age). 

(d)  The  early  eruptions  geii>3raUy  disappear  spontaneously  by  ab- 
sorption. 

Relapsing-  Syphilitic  Eruptions.  —  The  relapses  occur  after  the 
first  six  months,  and  differ  in  the  following  particulars  from  the  early 
eruptions: — 

Distribution. — (a)  While  they  may  be  distributed  over  the  entire 
body,  the  relapsing  eruptions  are  never  so  numerous  as  the  early 
lesions. 

(fc)  They  do  not  follow  the  lines  of  cleavage,  but  are  arranged  in 
circles  or  segments  of  circles. 

(c)  The  groups  of  lesions  do  not  tend  to  arrange  themselves  sym- 
metrically, as  a  rule,  but  have  certain  spots  of  predilection,  such  as  the 
genitals  and  anus,  the  mucous  membrane  of  the  mouth,  the  palms  and 


I 


Fig.  87. — Circinate  Sypliilide.  An  Early  Secondarj'^  lesion,  and 
variety  of  the  Maciilar  form  of  Sypliilide.  (Author's  Case,  from 
Polhemus  Clinic.) 


(301) 


Fig.  88.— Large  Papular  Syphilide.     (Courtesy  of  Dr.  Colby.) 


(303) 


I 


Fig.  89. — Malignant  Syphilis.    Pustular  Eruption.     (Author's  Case, 
from  Polhemus  Clinic.) 


(305) 


SKIN  ERUPTIONS,  OR  SYPHILIDES.  3O7 

soles,  the  upper  margin  of  the  forehead  near  the  hair,  and  the  flexures 
of  joints. 

(d)  The  later  eruptions  are  less  apt  to  be  absorbed  than  the  early 
lesions,  but  tend  rather  to  break  down  and  ulcerate. 

Course  of  the  Eruption.  —  Syphilides  are  temporary  formations 
which  grow  and  spread  at  the  periphery,  or  outer  edge,  and  after 
reaching  a  certain  height  absorption  or  ulceration  takes  place,  begin- 
ning in  the  centre. 

In  this  way  the  ring  formation  occurs.  The  centre,  or  oldest 
part,  has  been  absorbed  and  disappeared,  leaving  the  most  recently 
formed  portion  of  eruption  still  present  as  a  ring  around  the  healed 
centre. 

Retrogressive  Changes  of  Syphilides. — As  stated  above,  the  proc- 
ess of  absorption  always  begins  in  the  centre  of  the  lesion. 

The  macular  syphilide  disappears  most  readily,  and,  if  a  pig- 
mentation were  formed,  it  is  soon  absorbed,  leaving  the  skin  whiter 
than  normal. 

In  the  papule  the  central  part  is  absorbed,  leaving  a  depression, 
which  is  filled  with  epidermal  scales. 

The  pustule  is  formed  from  a  papule,  and  -has  a  crater-like  de- 
pression in  its  centre  filled  with  pus;  this  dries  up  and  forms  a  crust, 
and  the  surrounding  ring  of  infiltration  is  removed  by  absorption. 

The  papule  and  pustule  leave  traces  of  their  presence,  as  spots 
of  pigmentation,  which  remain  on  the'  site  of  the  original  lesion  for 
a  long  time. 

If  the  pustule  has  caused  much  necrosis  of  the  normal  cutaneous 
elements,  a  cicatrix  will  be  formed. 

Symptoms  of  Syphilides.  —  I.  Arrangement  of  the  lesions.  II. 
Polymorphism.    III.  Color.    IV.  Absence  of  burning  and  itching. 

I.  The  arrangement  has  already  been  considered,  and  depends 
entirely  on  whether  the  syphilide  is  early  or  one  of  the  later  relapsing 
eruptions. 

//.  Polymorpliism  is  the  most  valuable  diagnostic  sign  of  a  syph- 
ilide, and  pertains  to  both  early  and  late  varieties  of  eruption.  Poly- 
morphism may  be  defined  as  diverse  as  to  form,  and  is  brought  about 
in  the  following  way:  The  eruption  in  syphilis  never  comes  out  all  at 
once,  but  makes  its  appearance  in  successive  crops.  When  the  erup- 
tion is  viewed,  if  it  has  lasted  for  some  little  time,  it  may  be  noticed 
that  the  older  spots  have  undergone  transformation,  while  in  the  later 
spots  the  changes  are  less  marked.    Hence  we  find  present  at  the  same 


308  SYPHILIS  AND  ITS  LESIONS. 

time  macules,  papules,  and  pustules,  and  the  lesions  are  all  of  dif- 
ferent ages  and  various  stages  of  development  or  retrogression. 

///.  Color. — The  color  of  syphilides  is  frequently  compared  to 
that  of  an  old  copper  cent  or  of  lean  raw  ham.  The  color  is  by  no 
means  pathognomonic,  as  it  occurs  in  most  inflammations  of  the  skin 
which  are  chronic.  It  is  occasioned  by  the  arteritis,  which  weakens 
the  vessel-walls  and  allows  the  red  corpuscles  to  pass  out  into  the  sur- 
rounding tissues.  The  haemoglobin  loses  its  bright-red  color  and 
becomes  brown. 

IV.  The  absence  of  burning  and  itching  is  not  invariable,  but  is 
usual,  and  is  accounted  for  by  the  slow  chronic  character  of  the  de- 
velopment of  the  lesions. 

Duration  of  Secondary  Stage. — The  secondary  stage  lasts  a  vari- 
able length  of  time,  which  may  be  from  six  to  eighteen  months,  and 
may  be  set  down  as  about  one  year,  on  the  average. 

In  cases  which  follow  a  favorable  course  relapses  cease  to  occur, 
and  the  disease  appears  to  be  at  an  end. 

It  is  not  possible  to  draw  any  distinct  line  of  demarcation  be- 
tween the  secondary  and  tertiary  periods,  for  as  the  lesions  continue 
to  recur  they  gradually  lose  the  distinguishing  characteristics  of  sec- 
ondary syphilis  and  become  distinctly  tertiary. 

In  the  secondary  stage  the  visible  manifestations  of  the  disease 
occur  chiefly  upon  the  skin  and  mucous  membranes,  and,  while  the 
viscera,  eyes,  and  nervous  system  are  occasionally  attacked,  they  are 
not  apt  to  be  affected. 

In  the  tertiary  stage,  however,  the  affections  of  the  skin  are 
trivial  in  comparison  with  the  damage  which  may  be  wrought  in  other 
vital  organs. 


TERTIARY  STAGE. 

Individuals  who  are  strong  and  well  nourished  and  who  are  sys- 
tematically and  carefully  treated  for  a  sufficient  length  of  time  rarely 
develop  tertiary  symptoms. 

Tertiary  lesions  are  said  to  occur  in  from  5  to  40  per  cent,  of 
cases  of  syphilis.  The  most  usual  time  for  their  appearance  is  from 
three  to  five  years  after  infection,  although  long  periods  of  latency, 


M 


i^^^^'^^-:^. 


VTI.  Gumma  of  the  Testicle. 

a,  Central  portion,  seat  of  coagulation-necrosis.        />,  Peripheral  zone  formed  by  infiltration  of  small  ronnd  cells 
c,  Compressed  tubuli  seminileri.        d.  Interstitial  small  round-celled  infiltration. 


^%...: 


a^'-ri^. 


VIII.  Endarteritis  (Artery  from  the  Fi.ssure  of  Sylvius). 

o,  Swollen  and  infiltrated  endothelial  lining.  6.  New  formation  composed  of  connective  'J^'^"!,  »"•!  ""^''.'Xv. 

celled  infiltration.         c.  Membrana  elastica.         rf.  Muscular  coat.        e.  Med.a.         /,  Ad^entitia.    All  »Do>e 
lavers  infiltrated  with  small  ronnd  cells.        g.  Nutrient  artery  (vas  vasonim). 


(From  "Die  Syphilis  und  die  Venerischen  Krankheiten,"  von  Dr.  Ernest  Finger.) 


TERTIARY  STAGE. 


309 


I 


even  as  much  as  fifty  years,  during  which  the  patient  is  entirely  free 
from  symptoms,  may  intervene  before  the  tertiary  lesions  appear. 

Characteristics  of  Lesions  of  Skin  and  Mucous  Membrane. The 

characteristics  of  the  syphilides  in  the  tertiary  period  differ  greatly 
from  the  secondaries,  and  may  be  summarized  as  follows: — 

I.  They  attack  a  limited  area. 

II.  They  have  a  tendency  to  extend  and  cause  destruction  of 
tissue,  with  the  formation  of  scar-tissue  and  its  subsequent  contrac- 
tion. 

III.  They  do  not  tend  to  spontaneous  recovery,  but  rather  break 
down  and  ulcerate. 

IV.  They  extend  deeply  into  the  tissues. 

Tertiary  lesions,  in  whatever  organ  or  structure  of  the  body  they 
may  occur,  are  the  direct  result  of  chronic  vascular  lesions,  and  are 
commonly  accompanied  by  the  so-called  gumma. 


PATHOLOGY. 

Arterial  Changes.  —  In  the  tertiary  period  of  syphilis  arteritis 
plays  an  important  role.  In  the  secondary  period  the  inflammatory 
changes  in  the  vessels  are  more  apt  to  involve  the  adventiiia,  but  in 
tertiary  syphilis  the  inner  coat  is  more  liable  to  be  attacked. 

The  chronic  inflammation  of  the  vessel-walls  causes  an  infiltra- 
tion of  small  round  cells  to  take  place  between  the  intima  and  the 
endothelial  lining  of  the  artery,  and  this  infiltration  ultimately  becomes 
organized  into  connective  tissue.  The  contraction  of  the  tissue  thus 
formed  causes  a  narrowing  of  the  calibre  of  the  artery,  and,  indeed, 
it  may  lead  to  the  total  closure  of  its  lumen,  and  the  vessel  becomes 
transformed  into  a  solid  string  of  connective  tissue  (endarteritis 
obliterans). 

When  the  arterial  wall  is  the  seat  of  an  inflammatory  process 
which  is  very  circumscribed,  instead  of  its  lumen  becoming  narrowed 
or  obliterated  its  walls  may  be  stretched  and  dilated,  and  in  this  way 
small  miliary  aneurisms  are  formed. 

Gummous  arteritis  is  a  rare  affection,  consisting  in  the  formation 
of  small  gummata,  which  grow  from  the  media  and  push  upward, 
covered  by  the  unchanged  intima,  into  the  lumen  of  the  artery.  The 
centre  of  the  gumma  generally  becomes  cheesy  and  breaks  down. 
Obliterating  endarteritis  can  also  exist  at  the  same  point  in  the  vessel 
in  addition  to  the  gumma. 


310  SYPHILIS  AND  ITS  LESIONS. 

Gumma^  is  always  preceded  by  and  dependent  upon  the  arteritis. 
It  occurs  especially  in  the  skin,  periosteum,  meninges  of  the  brain  and 
cord,  and  the  abdominal  viscera,  particularly  the  liver,  spleen,  and 
testicle. 

The  gumma  consists  of  a  circumscribed  mass  of  new  tissue,  vary- 
ing in  size  from  a  pin's  head  to  a  hen's  egg,  and  is  composed  of  a 
hyaline  matrix,  in  which  are  imbedded  small  round  cells  and  occa- 
sionally giant  cells.  Small  gummata  may  disappear  by  absorption, 
but,  in  gummata  of  larger  size,  the  nutrition  of  the  central  parts  of 
the  tumor  is  cut  off,  by  the  pressure  of  the  hyperplastic  tissue  on  the 
blood-vessels  and  by  the  accompanying  endarteritis,  and  the  centre 
of  the  tumor  undergoes  coagulation-necrosis. 

After  a  gumma  has  lasted  for  some  time,  it  is  found  to  be  com- 
posed of  an  old  central  part  made  up  of  fatty,  cheesy,  broken-down 
cells  and  an  outer  zone  which  has  been  transformed  into  a  fibrous 
connective-tissue  envelope  surrounding  the  softened  sloughing  centre. 

A  gumma  may  exist  singly  or  there  may  be  several  present,  lying 
close  together.  The  circumscribed  form  of  gumma  developing  in  the 
skin  is  termed  a  sypliiliiic  tubercle. 


CLASSIFICATION  OF  SKIN  ERUPTIONS. 

The  eruptions  which  occur  upon  the  skin  in  tertiary  syphilis  are 
all  occasioned  by  the  formation  of  gummata  in  the  skin  or  subcu- 
taneous connective  tissue  and  their  subsequent  progress  of  ulceration, 
and  are  classified  as  follows: — 

I.  Gumma:     (a)  Of  the  skin.     (&)  Subcutaneous  tissue. 

II.  Tubercular  syphilide:     (a)  Dry  or  atrophic,     (h)  Ulcerative. 

III.  Eupial  S3'^philide. 

(a)  Gumma  of  the  Skin,  (b)  Gumma  of  the  Subcutaneous 
Tissues. — Gumma  of  the  subcutaneous  tissues  is  the  cause  of  the  deep 


'  The  name  of  infectious  granulomata  was  given  by  Virchow  to  a  class 
of  diseases  whose  development  does  not  pass  beyond  the  stage  of  formation 
of  granulation-tissue,  which  is  transitory  in  the  character  of  its  duration  and 
ends  by  ulceration.  In  addition,  it  is  nearly  allied  in  its  formation  to  the 
process  of  inflammation.  The  class  of  infectious  granulomata  includes  syph- 
ilis, tuberculosis,  leprosy,  actinomycosis,  mycosis  fungoides,  rhinoseleroma,  and 
glanders. 


Fig.  90. — Guminata  of  the  Tongue.  The  one  in  the  middle  has 
undergone  Coagulation-necrosis  of  its  centre.  (Author's  Case,  from 
Kings  County  Hospital.) 


Fig.  91. — Ulcerating  Gumma  of  the  Ankle.     (Author's  Case,  from 
Rings  County  Hospital.) 

(311) 


TERTIARY  STAGE. 


313 


ulcerations  commonly  met  with  in  tertiary  syphilis.  The  skin  lying 
above  the  gumma  becomes  attached  to  it  by  the  inflammation,  softens, 
and  sloughs  away,  exposing  to  the  air  the  cavity  which  was  formed 
in  the  central  part  of  the  gumma,  by  the  coagulatiifn-necrosis  of  the 
new  infiltrating  cells.  As  the  ulcers  heal,  a  cicatrix  is  formed  which 
dips  down  into  the  cavity  of  the  gumma  and  a  depressed  scar,  at- 
tached firmly  to  the  subcutaneous  tissues,  remains  at  that  point. 

The  circumscribed  form  of  gumma  which  develops  in  the  skin 
is  termed  a  syphilitic  tubercle.  This  condition  is  entirely  distinct 
from  tuberculosis  of  the  skin,  which  depends  upon  the  tubercle  ba- 
cillus, and  in  this  instance  the  Avord  tubercle  means  a  little  tuber,  or 
small  nodule.     The  tubercular  syphilide  appears  in  two  forms: — 

(a)  Dry,  or  atrophic,  tubercular  syphilide,  which  is  so  called 
from  the  fact  that  it  does  not  break  down  and  undergo  destruction, 
but  tends  to  dry  up  and  disappear  by  absorption. 

It  is  this  variety  of  syphilide  which  occasions  the  ringed  form 
of  eruption  which  comes  on  late  in  the  course  of  the  disease.  (See 
plate.) 

(b)  The  ulcerative  form  of  tubercular  syphilide  takes  its  name 
from  the  fact  that,  unlike  the  atrophic  form,  it  is  not  absorbed,  but 
breaks  down  and  ulcerates,  continually  spreading  'farther  at  the  edge 
and  healing  in  the  centre.  From  its  tendency  to  extend  at  the 
periphery  and  involve  fresh  areas  of  tissue  it  is  sometimes  termed  the 
serpiginous  syphilide. 

The  rupial  syphilide  derives  its  name  from  the  concentric  rings 
of  crust  which  form  the  scab,  resembling  the  rings  of  an  oyster-shell. 
The  formation  of  the  rings  occurs  in  this  manner:  A  small  gumma 
forms  in  the  skin,  ulcerates,  and  the  ulcer  is  covered  with  a  crust. 
The  ulceration  extends  at  the  periphery;  a  ring  of  crust  is  formed 
over  the  new  ulceration  and  lies  underneath  the  first  crust,  and  as  it 
is  larger  in  size,  projects  all  around  it.  As  the  ulceration  extends, 
other  layers  of  crust  are  formed  underneath  the  original  ones,  and 
each  additional  crust  which  forms  is  larger  in  diameter  than  the  one 
preceding  it,  and  is  not  entirely  covered,  so  that  the  edge  is  seen  form- 
ing a  ring  around  the  crust  above  it. 

The  lesions  above  described  are  all  deeply  seated,  involve  the 
subcutaneous  tissues,  and  result  in  more  or  less  destruction  of  tissue, 
whicli  is  healed  by  the  formation  of  contracting  cicatrices. 


314  SYPHILIS  AND  ITS  LESIONS. 


SYPHILIS  AND  IRRITATION. 

The  predilection  which  syphilitic  lesions  seem  to  show  for  cer- 
tain structures  may  be  partly  accounted  for  in  the  following  way:  It 
has  long  been  noticed  that  any  irritation  or  trifling  form  of  injury  in 
a  syphilitic  individual  predisposes  toward  the  formation  of  lesions  at 
the  injured  or  irritated  point.  Frequent  examples  may  be  called  to 
mind,  as,  for  instance,  the  effects  of  smoking  or  the  friction  from 
broken  teeth  in  causing  sores  in  the  mouth.  Pressure  contact,  if  oft 
repeated  and  prolonged, — as,  for  example,  the  pressure  of  the  forearm 
upon  a  desk,  in  a  clerk  or  book-keeper, — predisposes  to  the  appear- 
ance of  an  eruption  upon  the  skin  of  the  forearms.  A  slight  blow  or 
squeeze  may  induce  the  formation  of  gumma  in  the  bones  or  testicles, 
and,  as  would  naturally  be  expected,  the  bones  which  lie  near  the  sur- 
face of  the  skin — such  as  the  tibia,  ribs,  and  skull — are  more  apt  to 
be  affected  by  periostitis  than  the  bones  which  are  abundantly  covered 
by  a  thick  cushion  of  muscle  and  fat. 

Syphilitic  lesions  also,  by  preference,  affect  the  poijit  of  least  re- 
sistance in  the  organism.  Thus,  for  instance,  syphilis  of  the  liver  is 
more  frequent  in  alcoholics  than  in  abstemious  persons,  and  syphilis 
is  particularly  liable  to  attack  the  brain  and  its  meninges  in  indi- 
viduals who  are  mentally  active  and  are  brain-workers.  For  the  same 
Teason  a  relapse  of  a  syphilis,  which  has  been  latent  for  some  time, 
is  often  induced  by  an  attack  of  malnutrition  brought  on  by  want 
and  privation. 


MALIGNANT  SYPHILIS. 

Syphilis  is  said  to  be  malignant  when  it  pursues  a  rapid,  destruct- 
ive, and  uncontrollable  course  from  the  outset,  and  it  only  occurs  in 
individuals  who  are  debilitated  from  tuberculosis,  alcoholism,  or  bad 
nutrition  and  privation.  Its  severity  is  increased  from  the  fact  that 
such  cases  do  not  tolerate  the  administration  of  mercury  and  iodide 
of  potash  well. 

The  early  lesions  are  generally  distributed  over  the  body,  are 
pustular  in  character,  break  down,  and  cause  extensive  ulcerations. 
The  anaemia  from  the  destruction  of  the  red  corpuscles  is  very  marked, 


Fig.  92. — Kupial  Syphilide.     (Author's  Case,  from  Polhemus  Clinic.) 


(315) 


Fig.  93.— Pustular  Syphilide  (Malignant  Syphilis).     (Author's  Case, 
from  Kings  County  Hospital.) 


(317) 


IMMUNITY  IN  SYPHILIS.  3^9 

and  the  cachexia  is  strikingly  evident.  The  subcutaneous  fat  is  ab- 
sorbed, and  the  patient  emaciates. 

Gummata  develop  prematurely,  and  four  or  five  months  after 
infection  the  most  extensive,  wide-spread  forms  of  gummatous  ulcera- 
tion may  be  present.  Death  may  result  from  destruction  of  some 
vital  organ,  or  the  prolonged  suppuration  of  the  ulcers  may  cause 
death  from  amyloid  or  fatty  degeneration  of  the  viscera  or  general 
marasmus. 

If  the  resistance  of  the  system  be  enough  to  withstand  the  drain 
for  two  years,  the  virulence  of  the  disease  is  exhausted,  and  the  patient 
may  live,  but  in  a  weak  and  debilitated  condition  of  body. 


In  the  foregoing  sections  we  have  considered  the  manifestations 
of  syphilis  in  the  skin  and  mucous  membranes  only,  but,  as  has 
already  been  indicated,  the  lesions  of  syphilis  are  not  confined  to  any 
one  structure. 

The  pathological  processes  of  endarteritis  and  periarteritis,  with 
their  accompanying  cellular  infiltration  of  tissue  and  the  resulting 
degenerative  changes  in  neighboring  structures,  as  well  as  the  gum- 
matous infiltration  occurring  in  the  later  period  of  syphilis,  are  liable 
to  attack  any  organ  in  the  body,  and  the  symptoms  resulting  depend 
wholly  upon  the  function  of  the  organ  attacked. 

For  syphilitic  affections  of  the  muscles,  joints,  and  breast  the 
reader  is  referred  to  the  treatises  on  surgery,  and  to  the  works  on 
internal  medicine  for  an  account  of  syphilitic  disease  of  the  liver, 
heart,  spleen,  etc. 

The  diseases  of  the  nervous  system,  eye,  and  ear  which  depend 
upon  syphilis  for  their  causation  are  best  studied  in  the  special  text- 
books devoted  to  those  subjects. 


IMMUNITY  IN  SYPHILIS. 

Immunity  may  be  defined  as  the  condition  of  lody  which  resists 
I     the  growth  and  pathogenesis  of  disease-producing  germs. 
'  As  in  all  other  infectious  diseases,  one  attack  of  syphilis  protects 

j    against  others,  and  it  is  an  event  of  the  greatest  rarity  for  a  second 


320  SYPHILIS  AND  ITS  LESIONS. 

infection  to  occur.  The  essential  nature  and  cause  of  immunity,  in 
any  infectious  disease,  is  still  a  matter  of  speculation.  There  are 
three  theories  at  present  to  account  for  it: — 

I.  Phagocytosis. 

II.  The  bactericidal  power  of  the  blood. 

III.  The  antitoxins. 

The  latter  theory  is  not  fully  established,  but  is  more  generally 
accepted  than  either  of  the  others.  It  is  known  that  bacterial  action 
and  growth  produce  substances  called  toxins,  which  are  poisonous.  It 
is  supposed  that  another  set  of  chemical  substances  called  antitoxins, 
or  defensive  proteids,  is  being  formed  at  the  same  time.  The  anti- 
toxins do  not  destroy  the  toxins,  but  exert  some  action  upon  the  tis- 
sues of  the  body  which  causes  them  to  be  insusceptible  to  the  action 
of  the  toxins. 

Immunity  may  be  acquired  in  three  ways: — 

I.  By  means  of  a  first  attack. 

II.  By  means  of  heredity,  which  is  the  so-called  inherited  im- 
munity, and  is  demonstrated  by  the  fact  that  occasionally  healthy 
children  are  born  of  syphilitic  parents,  because  the  foetus  has  acquired 
its  immunity  in  utero. 

III.  Acquired  Immunity. — It  sometimes  happens  that  healthy 
mothers  who  become  pregnant  with  a  syphilitic  child  (infected  with 
syphilis  and  generated  by  a  syphilitic  father  at  the  same  time)  may 
acquire  immunity  through  absorption  of  the  syphilis  antitoxins  which 
had  been  formed  in  the  foetus. 


INHERITED  SYPHILIS. 

Infection. — Father  and  Mother  hoth  Syphilitic. — It  is  almost 
needless  to  say  that,  when  hoth  father  and  mother  are  syphilitic  at  the 
time  of  conception,  the  foetus  will  be  almost  invariably  infected.  The 
children  suffer  from  a  severe  form  of  syphilis,  and  usually  die. 

Mother  alone  Syphilitic  {Father  leing  Healthy). — If  the  mother 
acquired  her  syphilis  before  conception  the  child  is  almost  sure  to  be 
infected,  as  it  is  nourished  directly  by  the  maternal  blood  containing 


INHERITED  SYPHILIS. 


321 


the  syphilitic  virus.  If  the  mother  is  infected  with  syphilis  after 
conception,  but  during  the  pregnancy,  we  have  two  conditions  to  con- 
sider:— 

(a)  If  the  mother's  infection  has  occurred  in  the  early  months 
of  pregnancy,  before  the  independent  foetal  circulation  has  been  estab- 
lished, the  foetus  is  usually  infected  with  syphilis,  because  the  foetus 
is  nourished  directly  by  the  maternal  blood  containing  the  syphilitic 
virus. 

(&)  In  the  later  months  of  pregnancy,  however,  the  foetus  has 
its  own  independent  circulation.  The  villi  of  the  placenta  are  inter- 
posed between  the  foetal  and  maternal  circulation,  and  the  nutrient 
material  passes  from  the  mother  to  the  foetus,  not  by  direct  inter- 
change of  blood,  but  by  osmosis. 

If  the  mother  acquires  syphilis  after  the  establishment  of  an 
independent  foetal  circulation,  the  villi  of  the  placenta  may  filter  out 
and  prevent  the  virus  from  reaching  the  child;  but,  as  the  antitoxins 
are  held  in  solution,  they  will  pass  through  the  membrane  of  the 
placental  villi  and  exert  an  immunizing  action  upon  the  foetus.  Hence 
we  have  Prof  eta's  law  of  immunity :  "Children  may  be  born  of  syph- 
ilitic parents  and  remain  healthy,  and  present  an  immunity  against 
syphilis  which  is  either  absolute  or  else  modifies  the  syphilis  so  that 
it  runs  a  very  mild  course." 

Father  alone  Syphilitic  (Mother  leing  Healthy). — Under  this  head 
there  are  also  two  conditions  to  consider: — 

(a)  The  spermatozoa  may  contain  the  virus  and  carry  it  to  the 
ovum  at  the  time  of  conception,  and,  as  a  result,  the  child  is  syph- 
ilitic. The  syphilis  may  cause  the  death  of  the  foetus  in  utero,  inter- 
ference with  development,  or  simple  debility,  or  the  child  may  be 
born  syphilitic. 

Infection  of  the  foetus  by  the  father  is  the  most  common  form, 
but  the  syphilis  resulting  is  less  severe  than  in  the  other  forms  of 
infection,  for  the  reason  that  if  the  mother  remains  healthy  the  foetus 
is  nourished  with  healthy  blood  and  the  harmful  effects  of  the  syph- 
ilis are  partly  neutralized. 

(b)  The  spermatozoa,  however,  do  not  always  carry  the  virus  of 
syphilis  to  the  ovule,  and  the  child  often  escapes  infection  and  is  born 
healthy. 

Influence  of  the  Child's  Syphilis  as  Exerted  upon  the  Mother.— 
We  may  consider  now  the  instances  in  which  the  mother  is  free  from 
syphilis,  but  the  child  has  been  infected  by  the  father  at  the  time  of 


322  SYPHILIS  AND  ITS  LESIONS. 

conception.  The  effects  which  the  child's  syphilis  cause  in  the  mother 
must  he  divided  into  three  groups: — 

(a)  In  the  first  group,  the  mother  remains  entirely  unaffected, 
and  a  condition  of  immunity  is  not  established,  so  that  the  mother 
may  acquire  syphilis  from  her  own  child  after  its  birth  or  from  other 
sources.  These  cases  are  extremely  rare,  and  prove  an  exception  to 
the  generally  established  law  of  Colles. 

ih)  The  second  group  forms  a  large  number  of  cases,  and  com- 
prises the  instances  in  which  the  mother  is  infected  with  syphilis  from 
her  own  child,  during  its  term  of  gestation  in  the  uterus.  The  name 
given  to  this  mode  of  infection  of  the  mother  is  clioc  en  retour,  or 
syphilis  by  conception.  The  syphilitic  virus  formed  in  the  child  passes 
over  directly  into  the  mother's  blood,  through  the  placental  circula- 
tion. 

(c)  The  third  group  includes  the  cases  in  which  the  mother  is  not 
infected  from  the  child  in  utero,  but  becomes  immune  against  syphilis, 
and  is  described  by  Colles's  law,  viz.:  "A  syphilitic  child  cannot 
infect  its  own  mother  after  its  birth."  The  mother  acquires  immu- 
nity against  infection,  probably  from  absorption  of  the  antitoxin  of 
syphilis  which  is  formed  in  the  body  of  the  foetus.  It  is  supposed  that 
the  placental  villi  act  as  a  filter,  and  allow  the  antitoxins,  which  are 
in  a  state  of  solution,  to  pass  through  them,  by  osmosis,  into  the 
maternal  blood,  but  prevent  the  virus  from  reaching  the  mother's 
circulation  in  any  great  quantity. 

Length  of  Time  After  the  Chancre  at  which  Infection  of  the 
Foetus  or  Choc  en  Retour  is  Liable  to  Occur. — Syphilis  is  most  liable 
to  be  communicated  to  the  foetus  or  by  choc  en  retour  during  the  sec- 
ondary period  and  the  first  three  or  four  years  after  the  primary  sore. 
As  time  passes  the  intensity  of  the  syphilis  also  diminishes,  as  is  shown 
by  the  following  table: — 

Termination  of  Pregnancies  in  a  Syphilitic  Mother.  —  I.  First 
pregnancy  terminates  in  an  abortion. 

II.  The  next  pregnane}'  results  in  the  premature  birth  of  a  syph- 
ilitic child. 

III.  Then  follows  the  birth  of  a  full-term  child,  which  has  syph- 
ilitic manifestations. 

IV.  Next  a  child  is  born  at  full  term,  which  subsequently  de- 
velops manifestations  of  syphilis. 

V.  Finally  healthy,  full-term  children  are  born  which  remain 
healthy  and  free  from  syphilis. 


SYPHILIS  AND  MARRIAGE.  333 

It  is  important  to  bear  in  mind  that  the  inheritance  of  syphilis 
by  the  child  can  be  favorably  influenced  or  absolutely  prevented  by 
treating  the  syphilis  of  the  parents,  both  before  and  after  conception, 
with  mercury. 

As  a  result  of  the  observations  made  in  regard  to  inherited  syph- 
ilis, the  following  principles  can  be  applied  practically: — 

I.  A  man  or  woman  with  syphilis  should  not  be  allowed  to  marry 
until  three  or  four  years  have  elapsed  since  the  original  infection,  and 
methodic  treatment  should  be  carried  out  during  this  period. 

II.  If  a  married  man  or  woman  acquire  syphilis,  he  or  she  should 
be  energetically  treated,  in  order  to  lesson  the  danger  of  infection  of 
the  foetus  in  case  pregnancy  should  occur. 

III.  A  pregnant  woman  with  syphilis  should  be  energetically 
treated  during  the  entire  period  of  pregnancy. 

IV.  If  a  woman  free  from  syphilis  becomes  pregnant,  by  a  syph- 
ilitic man,  she  should  be  treated,  to  prevent  the  danger  of  choc  en 
retour. 

V.  A  syphilitic  child  should  only  nurse  from  its  mother,  and 
never  be  allowed  to  nurse  from  a  wet-nurse. 

VI.  A  child  apparently  health}',  although  born  of  syphilitic 
parents,  should  never  be  allowed  to  nurse  from  a  wet-nurse,  until  at 
least  three  months  have  elapsed  without  any  symptoms  of  syphilis 
developing  in  the  child.  • 

The  relation  which  the  question  of  marriage  bears  to  syphilis  is 

an  important  one.    The  lesions  of  tertiary  syphilis  are  not  contagious, 

and  in  most  cases  the  infectious  element  has  disappeared  after  the 

lapse  of  two  years;  still  it  is  necessary  to  bear  in  mind  that  a  syphilitic 

father  may  propagate  a  diseased  child,  which  may  be  still-born  or 

;  infect  the  mother  by  choc  en  retour,  up  to  the  end  of  the  third  or 

j  fourth  year.    On  this  account  a  set  of  working  rules  might  be  formu- 

}  lated  as  follows: — 

j  I.  No  one  showing  signs  of  active  syphilis  should  be  allowed  to 

i  marry,  even  though  more  than  four  years  have  elapsed  since  the  pri- 
t  mary  infection. 


324  SYPHILIS  AND  ITS  LESIONS. 

II.  Marriage  should  never  be  sanctioned  until  at  least  three  years 
have  elapsed  after  infection,  provided  the  patient  has  been  systematic- 
ally treated  during  that  time:  but  four  years  is  a  safer  time-limit, 
and  patients  should  be  advised  to  wait  for  that  length  of  time. 

III.-  Marriage  should  not  be  permitted  until  at  least  one  year  has 
passed  during  which  no  symptoms  have  appeared. 


DIAGNOSIS  OF  SYPHILIS. 

The  question  of  diagnosis  is  an  important  one,  both  from  the 
stand-point  of  therapeutics  and  also  from  the  necessity  of  guarding 
other  persons  against  a  contagious  disease.  Of  course,  it  is  more  dif- 
ficult oftentimes  to  make  a  diagnosis  many  years  after  infection  than 
when  the  initial  lesion,  mucous  patches,  and  eruption  are  all  present. 
It  is  always  better  to  conduct  the  examination  in  a  S5^stematic  man- 
ner, and  begin  by  taking  the  history  of  the  case. 

We  should  inquire  if  the  patient  has  suffered  from:  (a)  a  venereal 
sore  with  lumps  in  the  groin;  followed  by  (h)  a  rash  upon  the  skin,  (c) 
sore  throat  or  sores  in  the  mouth,  (d)  pains  in  the  bones  and  skull 
which  were  worse  at  night,  (e)  sore  eyes,  and  (f)  in  women  the  occur- 
rence of  abortion  or  still-births. 

It  is  important  to  bear  in  mind  that  syphilis  is  not  always  ac- 
quired by  venereal  contact,  and  the  initial  lesion  may  not  have  been 
on  the  genital  organs.  We  should  also  remember  that  the  early  mani- 
festations may  have  been  so  slight,  particularly  in  women,  as  not  to 
have  been  noticed. 

It  is  well  to  bear  in  mind  that  in  men  there  is  a  possibility  of 
the  chancre  being  located  within  the  urethra,  without  causing  any 
symptoms  except  a  slight  gleety  discharge,  which  might  be  mistaken 
for  a  urethritis.  The  glandular  enlargement,  which  is  such  a  valuable 
diagnostic  sign,  disappears  after  two  years  and  is  unavailable. 

Late  in  the  tertiary  period  the  diagnosis  often  presents  great 
difficulties.  There  are,  however,  certain  points  for  examination  which 
may  throw  some  light  on  the  nature  of  the  case: — 

The  skin  and  mucous  membranes  should  be  examined  for  cica- 
trices. The  lones  and  testes  may  show  irregularities  or  swellings.  The 
eyes  often  show  decided  changes.  Local  paralysis  of  an  ocular  muscle 
is  a  valuable  diagnostic  sign.    Iritic  adhesions  may  be  present,  or  there 


PROGNOSIS  OF  SYPHILIS.  325 

may  be  changes  in  the  deeper  structures.  B.  Sachs  regards  the  action 
of  the  pupits  as  a  very  important  sign.  The  changes  which  occur  in 
syphilitic  cases,  without  previous  demonstrable  ocular  disease,  are  as 
follow:  I.  Inequality  of  pupils.  II.  Unequal  response  to  light  in  one 
pupil,  but  not  in  the  other.  III.  Complete  immobility  to  light  and 
accommodation.  IV.  Departure  from  the  circular  form  of  the  pupil 
without  preceding  iritis. 

In  doubtful  cases  the  diagnosis  is  sometimes  made  by  the  effects 
of  the  administration  of  mercury  and  iodide  of  potash.  If  the  lesions 
improve,  it  is  supposed  that  they  were  of  syphilitic  origin.  This  is 
a  very  uncertain  and  misleading  method  of  trying  to  get  at  the  truth, 
for  the  reason  that  mercury  and  iodide  of  potash  will  often  cause  the 
absorption  of  newly-formed  inflammatory  infiltration,  irrespective  of 
its  cause.  The  results  of  an  inflammation  which  was  due  to  the 
irritation  of  any  toxic  agent  in  the  blood — either  uric  acid,  alcohol, 
or  syphilis — will  be  absorbed  under  the  use  of  mercury  and  iodide, 
although  the  infiltration  due  to  syphilis  disappears  more  quickly  than 
the  others.     (See  chapter  on  "Inherited  Syphilis.") 


PROGNOSIS  OF  SYPHILIS. 

The  danger  to  life  in  syphilis  in  the  adult  depends  upon  the 
involvement  of  some  vital  organ  by  endarteritis  or  gummatous  infil- 
tration, and  this  frequently  occurs  years  after  infection,  when  the 
syphilis  is  supposed  to  be  extinct. 

The  ultimate  recovery  of  a  patient  with  syphilis  depends  upon 
the  following  factors: — 

I.  On  the  systematic  thoroughness  and  length  of  time  wbich  the 
case  is  treated. 

II.  On  the  constitution  of  the  patient. 

III.  On  the  virulence  of  the  poison. 

Any  cause  which  tends  to  depress  the  general  health — such  as 
privation,  bad  hygienic  surroundings,  overwork,  anxiety,  loss  of  sleep, 
and  particularly  habits  of  alcoholic  indulgence — retard  recovery. 

As  in  most  other  diseases,  the  extremes  of  life — that  is,  old  per- 
sons and  young  children — bear  syphilis  badly,  and  the  death-rate, 
particularly  in  children,  is  high. 

Women  are  believed  by  some  German  observers  to  be  less  severely 


32(3  SYPHILIS  AND  ITS  LESIONS. 

affected  than  men,  and  are  thought  to  be  less  liable  to  syphilitic  affec- 
tions of  the  nervous  system. 

Among  the  early  prognostic  indications  it  is  thought  that,  when 
the  glandular  enlargement  is  slight,  the  syphilis  will  run  a  mild  course. 

The  appearance  of  tertiary  lesions  prematurely,  and  in  the  early 
months  after  infection,  is  a  very  unfavorable  prognostic  sign. 

Extragenital  chancres — i.e.,  those  which  are  located  on  the  finger, 
breast,  lip,  etc. — are  more  apt  to  be  followed  by  a  severe  attack  of 
syphilis  than  in  the  cases  where  the  chancre  is  located  upon  the 
genitals. 


CHAPTER  XXII. 

TREATMENT  OF  SYPHILIS. 

As  SYPHILIS  is  a  general  and  constitutional  disease,  dependent 
upon  a  specific  poison,  it  is  necessary  to  introduce  a  remedy  into  the 
circulation  which  will  cause  either  an  elimination  of  the  poison  or 
else  neutralize  it  and  render  it  inert  and  harmless.  The  drugs  which 
are  the  mainstay  in  the  treatment  of  syphilis  are  mercury  and  iodide 
of  potash. 

Mercury  is  supposed  to  have  a  direct  action  upon  the  syphilitic 
virus,  destroying  and  neutralizing  it. 

Mercury  may  be  introduced  into  the  organism  by  three  routes: — 

I.  Through  the  skin:    (a)  by  inunction;    (b)  by  fumigation. 

II.  Under  the  skin  by  hypodermic  injection. 

III.  Through  the  intestinal  canal. 

It  is  eliminated  by  the  kidneys,  intestinal  glands,  and  by  the 
mucous  membrane  of  the  mouth  and  salivary  glands. 

After  a  varying  quantity  of  mercury  has  been  given  for  some 
time,  the  blood  becomes  saturated  with  it,  and  this  is  announced  by 
the  occurrence  of  mercurial  stomatitis,  which  is  ushered  in  by  certain 
prodromal  symptoms: — 

(a)  A  coppery  taste  in  the  mouth. 

(b)  An  increased  flow  of  saliva. 

(c)  Slight  pain  on  striking  the  teeth  together. 

(d)  Slight  swelling  and  sponginess  of  the  gums  next  the  teeth. 

In  mild  cases  of  ptyalism  the  symptoms  all  subside  in  a  few  days 
if  the  administration  of  the  drug  is  stopped;  but,  if  an  excessive 
quantity  of  mercury  has  been  introduced  into  the  body,  or  if  an  un- 
usual susceptibility  to  the  action  of  mercury  is  present,  the  toxemia 
is  indicated  by  salivation. 

In  severe  cases  of  salivation  the  gums  and  buccal  mucous  mem- 
brane are  greatly  swollen  and  ulcerated.  The  teeth  loosen  and  fall 
out,  the  saliva  pours  out  from  the  mouth  in  quantities,  even  to  the 
extent  of  several  pints  in  the  day,  and  the  breath  has  an  intensely 
foetid  odor. 

In  the  administration  of  mercury  in  syphilis  it  is  essential  to 

(327) 


323  SYPHILIS  AND  ITS  LESIONS. 

give  a  sufficient  quantity  of  the  drug  to  produce  ptijaUsm,  or  to  "touch 
the  gums/'  as  it  is  usually  called,  as  this  symptom  indicates  that  the 
patient  is  getting  the  requisite  quantity  of  mercury  to  hold  the  dis- 
ease in  check.  But  care  should  always  be  taken  to  stop  the  mercury 
before  salivation  is  induced. 

A  bad  condition  of  the  mouth  and  carious  broken  teeth  covered 
with  tartar  cause  the  mouth  to  react  prematurely  to  the  influence  of 
mercury,  and  for  this  reason  the  patient  should  go  to  a  dentist  and 
have  the  teeth  put  in  order,  before  beginning  treatment. 

Treatment  of  Salivation. — The  foetor  of  the  breath  and  the 
ulceration  can  be  best  checked  by  means  of  chlorate  of  potash  in 
solution  used  as  a  mouth-wash,  and  it  should  also  be  given  internally 
in  doses  of  20  grains  three  times  a  day.  The  pain  in  the  gums  induced 
by  mastication  can  be  lessened  by  brushing  the  gums  with  a  4-per- 
cent, cocaine  solution  before  eating,  although  in  severe  cases  the  pa- 
tient should  be  fed  upon  liquid  food.  The  excessive  secretion  of 
saliva  is  controlled,  to  some  extent,  by  hypodermic  injections  of 
atropine. 


MODES  OF  ADMINISTERING  MERCURY. 

Inunction. — The  method  of  rubbing  mercurial  ointment  into  the 
skin  is  the  most  sure  and  effective  mode  of  treating  an  ordinary  case 
of  syphilis,  and  is  the  only  plan  of  treatment  to  use  in  the  presence  of 
grave  lesions  threatening  life  or  the  integrity  of  vital  organs. 

The  advantage  of  inunction  is  its  prompt  action  in  saturating 
the  body  with  mercur}^  and  it  is  possible  to  give  three  times  the 
quantity  of  mercury  in  this  way  which  could  be  given  by  the  mouth. 
At  the  same  time  the  stomach  digestion  is  not  interfered  with,  and 
the  patient  can  assimilate  the  maximimi  quantity  of  food,  and  his 
nutrition  is  maintained. 

The  mercury,  through  the  friction  and  pressure  of  rubbing,  is 
pressed  into  the  open  mouths  of  the  sebaceous  follicles  and  sweat- 
ducts  in  the  skin.  It  is  brought  gradually  in  contact  with  the  blood 
circulating  in  the  capillaries  of  the  papillary  layer  in  the  skin,  and 
is  supposed  to  be  converted  into  bichloride  of  mercury  through  com- 
bination with  the  sodium  chloride  in  the  blood.  In  this  soluble  form 
it  is  thought  to  pass  into  the  general  blood-circulation.  The  mercury 
is  stored  up  in  the  follicles  of  the  skin  for  a  long  time  after  the  inunc- 


MODE  OF  ADMINISTERING  MERCURY.  329 

tions  have  been  discontinued,  and  can  be  found  eliminated  by  the 
urine  many  weeks  after  the  last  inunction  was  given. 

The  blue  ointment,  or  unguentum  hydrargyrum,  is  the  best 
preparation  to  use,  and  it  is  preferable  to  have  it  made  after  the 
formulary  of  the  German  pharmacopoeia,  which  contains  20  grains  of 
metallic  mercury  in  every  drachm  of  lard.  In  ordinary  cases  1  drachm 
is  a  suitable  dose,  but  in  exceptional  cases  2  drachms  may  be  used. 

It  is  well  to  have  the  druggist  measure  out  the  daily  dose  of  oint- 
ment and  inclose  it  in  waxed  paper.  The  ointment  should  be  very 
thoroughly  rubbed  into  the  skin,  selecting  a  fresh  portion  of  the  sur- 
face of  the  body  for  each  day's  rubbing,  and  it  is  not  practicable  for 
the  patient  to  rub  himself,  but  the  inunction  should  be  made  by  an 
attendant  or  masseur. 

It  requires  from  twenty  to  thirty  minutes'  firm  rubbing  with 
the  uncovered  hand  to  cause  the  complete  absorption  of  the  entire 
quantity  of  ointment  used. 

It  is  also  desirable  to  make  the  inunctions  in  a  regular  course,  as 
follows: — 

First  day:   In  the  calves. 

Second  day:   Inner  and  outer  sides  of  the  thigh. 

Third  day:    Chest  and  abdi'men.  "  ,' 

Fourth  day:   Flexor  surfaces  of  arms. 

Fifth  day:   Back. 

On  the  sixth  day  the  patient  takes  a  warm  bath  with  soap,  and 
on  the  seventh  day  begins  again  with  another  course  of  rubbings. 

It  requires  from  20  to  50  inunctions,  as  a  rule,  to  induce  ptyalism, 
and  the  gums  should  ie  touched  in  every  case  before  the  inunctions  are 
discontinued.  The  inunction  should  be  used  in  both  secondary  and 
tertiary  periods  whenever  danger  threatens  a  vital  organ,  such  as  the 
eye,  brain,  larynx,  etc.,  and  also  in  obstinate  ulcerative  processes  with 
rapid  destruction  of  tissue.  Inunction  is  also  the  most  reliable  means 
of  treating  the  ordinary  mild  cases  of  syphilis. 

Fumigations  of  calomel  are  a  useful  adjunct  to  other  treatment 
in  the  cases  of  early  lesions,  which  are  extensive  and  have  a  tendency 
to  involve  the  deeper  structures,  ulcerate,  and  extend.  The  calomel- 
fumes  come  directly  in  contact  with  lesions,  and  the  local  action  of 
the  vapor  of  mercury  facilitates  their  healing. 

Method  of  Application.  —  The  patient  sits  on  a  cane-bottomed 
chair  with  a  blanket  around  his  neck,  falling  to  the  floor  and  sur- 
rounding him  in  a  sort  of  tent.     The  head  is  left  uncovered.    A  tin 


330  SYPHILIS  AND  ITS  LESIONS. 

pan  holding  boiling  water  is  placed  under  the  chair,  and  the  patient 
steamed  for  fifteen  minutes.  The  pan  is  then  withdrawn  and  30 
grains  of  calomel  are  fumigated  on  a  tin  stand,  over  a  spirit-lamp 
placed  underneath  the  chair,  and  the  patient  is  allowed  to  remain  sur- 
rounded by  the  fumes  for  half  an  hour.  The  fumigation  should  be 
employed  once  a  day  until  the  gums  are  touched. 

Sublimate  baths  are  employed  in  the  same  class  of  cases,  viz.: 
extensive,  ulcerating,  suppurating  lesions.  The  intact  skin  does  not 
permit  a  trace  of  sublimate  in  solution  to  be  absorbed,  but  absorption 
can  take  place  through  solutions  of  continuity. 

Intramuscular  Injections. — The  former  practice  of  injecting 
corrosive  sublimate  in  solution  under  the  skin  has  been  practically 
abandoned;  its  place  is  taken  by  the  insoluble  salts:  calomel  and 
salicylate  of  mercury,  held  in  emulsion  and  injected  deep  into  the 
substance  of  the  gluteal  muscles.  An  ordinary  hypodermic  syringe 
is  used,  provided  with  a  needle  which  is  two  inches  long  and  with  a 
thick  bore.  In  ordinary  cases  the  injection  is  made  once  a  week,  and, 
in  general,  the  salicylate  of  mercury  is  to  be  preferred  to  the  calomel. 
Formula: — 

IJ  Hydrargyri  salicylatis gr.  xxiij. 

Lanolini   gr.  xv. 

Oleum    olivae mccxviij. 

M.  Sig.  :  Inject  fifteen  minims  hypodermically  once  a  week.  Fifteen 
minims  contain  gr.  iss  of  the  salicylate  of  mercury. 

The  advantages  of  intramuscular  injections  are  that  they  act 
promptly  and  rapidly,  and  are  almost,  if  not  quite,  as  efficacious  as 
inunctions.  The  dosage  is  accurate,  and  the  injection  is  only  made 
once  a  week,  so  that  the  patient  is  relieved  from  the  annoyance  of 
taking  medicine  or  making  inunctions  in  the  intervals. 

The  disadvantages  are  the  pain,  which  is  very  inconsiderable,  and 
the  slight  chance  of  the  occurrence  of  abscess,  which  seldom  happens. 

In  exceptional  cases  the  oil  has  been  known  to  form  a  pulmonary 
embolus,  with  a  localized  pneumonia,  but  recovery  followed  in  each 
case. 

Salivation  may  occur  in  a  small  proportion  of  cases,  without  any 
previous  warning,  and,  as  the  deposit  of  mercury  is  in  the  muscle,  we 
cannot  stop  its  absorption  unless  an  incision  is  made  into  the  muscle 
and  the  small  mass  of  mercury  removed  by  a  curette. 

Administration  of  Mercury  by  Mouth. — "While  in  Germany  the 


MODE  OF  ADMINISTERING  MERCURY.  33 1 

usual  method  of  administering  mercury  is  by  inunction,  in  this  coun- 
try it  is  the  custom  to  treat  syphilis  by  its  internal  administration. 

In  recent  times,  however,  we  are  coming  to  the  conclusion  that 
it  is  not  enough  to  rely  wholly  upon  giving  mercury  by  the  mouth, 
but  that  its  action  should  be  supplemented  by  regular  courses  of 
inunction  at  different  times,  during  the  progress  of  the  disease,  in 
order  to  attain  a  cure  of  the  syphilis. 

If  mercury  is  given  by  the  mouth,  after  a  certain  length  of  time, 
the  absorptive  powers  of  the  intestinal  canal  often  become  impaired, 
and  the  mercury  passes  through  the  alimentary  tract  unchanged,  and 
without  being  absorbed.  Its  continuous  use  for  a  long  period  of  time 
often  causes  anaemia,  emaciation,  and  diarrhoea. 

The  internal  administration  of  mercury  is  appropriate  during  the 
intervals  of  inunction  and  in  the  periods  of  latency  of  syphilis,  but  it 
should  never  be  depended  upon  in  severe  cases  or  grave  complications. 
These  require  the  mercury  to  be  given  by  inunction  or  hypodermic 
injection. 

Preparations  of  Mercury. — Pills  of  protiodide  of  mercury  (La- 
moureux  &  Garnier),  ^/^  grain  each. 

MetJiod  of  Administration. — One  pill  is  given  three  times  a  day 
after  eating,  and  every  third  day  the  dosage  is  iiicreased  by  one  pill. 
For  example,  the  patient  takes  3  pills  for  3  days,  and  on  the  4th  day 
he  takes  4  pills,  and  on  the  8th  day  the  dose  is  increased  to  5  pills,  and 
so  on  up  to  the  point  of  tolerance,  which  is  usually  from  10  to  15  pills 
or  more. 

The  point  of  tolerance  is  not  manifested  by  ptyalism,  except  in 
rare  instances,  but  by  diarrhea  and  cramps.  When  these  symptoms 
occur,  the  dosage  is  reduced  to  a  point  just  short  of  producing  cramps. 

According  to  the  recommendation  of  Keyes,  the  full  dosage  is 
continued  until  a  period  of  latency  occurs,  when  it  is  reduced  to  one- 
half  the  number  of  pills  and  continued.  If  a  relapse  takes  place,  the 
maximum  dose  is  given  again. 

Another  plan  of  treatment,  which  is  more  to  be  commended,  is 
to  ascertain  the  maximum  dose  by  gradually  increasing  the  number 
of  pills,  and,  after  the  maximum  dose  is  reached,  it  is  maintained, 
without  reduction,  throughout  the  whole  course  of  the  disease,  unless 
anaemia,  emaciation,  diarrhoea,  or  salivation  are  produced  by  it. 

Mercury  with  ChalTc  {Eydrargyrum  cum  Cre^a).— This  is  a  mild 
preparation,  and  is  not  apt  to  induce  colic,  and  for  that  reason  it  may 
be  given  when  the  protiodide  produces  too  much  diarrhoea.     The 


333  SYPHILIS  AND  ITS  LESIONS. 

method  of  administration  is  similar  to  that  of  the  protiodide.  It 
may  be  given  in  1-grain  pills  and  increased  to  the  point  of  tolerance, 
which  is  manifested  by  either  ptyalism  or  diarrhoea. 

Bichloride  of  Mercury. — Dose,  ^/go  to  ^/js  grain.  This  form  of 
mercury  is  very  useful,  and  is  of  particular  value,  given  in  com- 
bination with  iodide  of  potash,  later  in  the  disease  in  the  form  of  the 
so-called  mixed  treatment. 

Tannate  of  Mercury. — Dose,  ^/^  to  1  grain  three  times  a  day. 
This  is  one  of  the  newer  preparations,  and  it  is  said  to  have  the  ad- 
vantage of  causing  very  little  irritation  to  the  intestinal  canal. 

Iodide  of  Potash. — The  iodide  of  potash  has  no  direct  action  in 
destroying  the  virus  of  syphilis,  and  consequently  it  is  of  no  use  early 
in  the  disease.  Its  action  is  to  cause  the  absorption  of  the  new  growth 
infiltrating  the  arteries  and  which,  when  it  occurs  in  other  tissues, 
is  known  as  the  gumma.  The  iodide  in  small  doses  acts  as  a  tonic,  and 
increases  appetite,  nutrition,  and  tissue-change. 

The  unpleasant  effects  which  are  induced  by  iodide  of  potash 
are  coryza  and  lachrymation,  and  an  eruption  upon  the  skin,  which 
usually  occurs  upon  the  back,  chest,  and  face  as  small  acneiform 
pustules.  In  rare  cases  large  hullcB  may  form  or  the  eruption  may  be 
hemorrhagic  in  character  and  resemble  purpura. 

In  addition,  there  is  often  a  condition  of  anamiia,  weakness,  and 
general  malaise  induced.  These  symptoms  are  all  less  apt  to  occur 
if  the  kidneys  secrete  freely  and  the  iodide  is  rapidly  eliminated. 

Dose  and  Administration. — The  only  rule  for  the  size  of  the  dose 
is  the  effect  produced  upon  the  lesion.  For  the  ordinary  routine  treat- 
ment, during  a  period  of  latency,  30  or  40  grains  a  day  are  enough, 
but,  in  the  presence  of  a  grave  lesion  of  the  nervous  system  or  viscera, 
V2  ounce  or  even  1  oimce  in  the  day  may  be  required  to  save  life. 

Iodide  of  potash  is  best  given  in  saturated  solution,  1  minim  of 
distilled  water  representing  1  grain  of  the  salt.  It  should  be  given 
largely  diluted  with  water,  and  preferably  two  hours  after  a  meal,  as 
the  iodide  combines  with  the  starch  in  the  stomach  and  forms  iodide 
of  starch,  which  is  inert. 

When  the  drug  disagrees  with  the  stomach  and  disturbs  the 
digestion,  it  may  be  given  in  milk,  which  is  coagulated  with  essence 
of  pepsine,  or  the  patient  may  be  directed  to  drink  one  or  two  glasses 
of  hot  water  immediately  after  taking  the  iodide. 

Zittmann's  Decoction. — This  is  one  of  the  official  preparations  of 
the  pharmacopoeia,  and  is  composed  of  a  number  of  vegetable  bitters 


1 


THERAPEUTICS  OF  SYPHILIS.  333 

together  with  a  minute  quantity  of  metallic  mercury.  Its  action  is 
first  purgative  and  later  tonic,  and  in  some  way,  which  is  not  under- 
stood, it  exercises  a  most  beneficial  effect  in  indolent,  spreading  ulcera- 
tions which  do  not  respond  to  mercury  and  iodide  of  potash.  These 
lesions  chiefly  occur  in  malignant  syphilis  affecting  persons  of  feeble 
vitality,  who  are  usually  of  the  tubercular  diathesis  and  who  cannot 
tolerate  mercury  or  iodide  of  potash  in  any  considerable  quantities. 

The  hot  springs  of  Arkansas  and  Aachen  in  Germany  are  useful 
in  the  same  class  of  cases,  viz.:  inveterate  syphilis  occurring  in  feeble 
individuals  whose  susceptibility  to  mercury  and  iodides  is  so  extreme 
that  they  cannot  be  administered  in  sufficient  doses  to  hold  the  disease 
under  control.  The  water  of  these  springs  contains  very  little  mineral 
substance,  but  has  a  temperature  of  140°  F.  as  it  issues  from  tlie 
earth.  Its  action  is  to  cause  free  secretion  by  the  kidneys  and  skin, 
and,  while  it  has  no  specific  action  upon  the  lesions  of  syphilis,  it 
increases  the  tolerance  of  the  body  and  enables  the  patient  to  take 
large  doses  of  mercury  and  the  iodides. 


THERAPEUTICS  OF  SYPHILIS. 

TREATMENT  OF  DIFFERENT  STAGES. 

Primary  Stage.— It  is  now  generally  held  by  the  best  authorities 
that  it  is  not  good  practice  to  begin  the  administration  of  mercury 
in  syphilis  until  the  eruption  appears  upon  the  skin,  announcing  the 
commencement  of  the  secondary  stage.  If  mercury  is  given  before 
this  time,  it  has  only  the  effect  of  delaying  the  appearance  of  the  rash, 
and  it  may  be  postponed  for  some  months,  but  the  premature  admin- 
istration of  mercury  has  no  effect  in  aborting  the  disease  or  mitigating 
its  severity.  On  the  other  hand,  it  has  been  noted  by  Ehrmann  that 
patients  who  were  treated  with  mercury  for  some  time  previous  to 
the  appearance  of  the  eruption  were  more  liable  to  tertiary  affections 
than  in  the  cases  where  treatment  was  not  begun  until  the  secondary 
period. 

Another  advantage  which  is  derived  from  waiting  till  secondary 
manifestations  appear,  before  beginning  treatment,  is  that  the  diag- 
nosis is  fully  established  and  the  patient,  being  entirely  convinced 
that  he  has  syphilis,  is  more  willing  to  carry  out  faithfully  the  details 
of  a  protracted  course  of  treatment. 


33i  SYPHILIS  AND  ITS  LESIONS. 

The  period  of  waiting  for  secondarj'  manifestations  can  be  util- 
ized b}'  sending  the  patient  to  a  dentist  to  have  the  teeth  put  in  order. 
He  should  also  be  instructed  as  to  the  hygiene  to  be  maintained  dur- 
ing the  course  of  the  disease.  Everything  should  be  done  to  main- 
tain the  bodily  health  and  nutrition;  plenty  of  sleep  and  exercise  in 
the  open  air,  abundance  of  plain  nutritious  food,  and  freedom  from 
overwork  or  anxiety  should  be  insisted  upon. 

The  use  of  tobacco  should  be  interdicted,  as  it  causes  an  irritation 
to  the  mucous  membrane  of  the  mouth,  which  predisposes  to  the 
formation  of  mucous  patches  and  chronic  ulceration  and  tends  to 
retard  their  healing. 

Alcoholic  drinks  in  strict  moderation  may  be  permitted  in  the 
shape  of  small  quantities  of  beer  or  light  wine,  taken  preferably  with 
the  meals.    The  habitual  use  of  whisky  is  injurious. 

The  patient  should  be  instructed  with  regard  to  the  danger  of 
communicating  syphilis  to  others,  through  the  medium  of  a  cup, 
spoon,  pipe,  towel,  or  other  utensil,  or  by  means  of  sexual  intercourse 
or  kissing. 

Mild  Form  of  Syphilis. — As  the  virus  of  syphilis  is  being  con- 
stantly formed  and  is  present  in  the  blood  for  months,  it  is  necessary, 
in  order  to  neutralize  its  effects,  to  keep  the  patient  continually  under 
the  influence  of  mercury. 

Before  beginning  treatment  we  should  wait  until  the  eruption  is 
well  out  upon  the  body,  and,  as  the  virus  is  most  abundant  in  the  early 
stages  of  the  disease,  it  is  always  desirable  to  push  the  administration 
of  the  mercury  at  first. 

A  sufficient  number  of  courses  of  mercurial  inunctions  should  be 
given  to  touch  the  gums,  and  the  drug  should  then  be  stopped  for 
a  time  until  the  ptyalism  has  disappeared.  During  the  following  six 
months  mercury  should  be  administered  by  the  mouth,  and,  as  a  rule, 
the  protiodide  pill  answers  the  purpose  better  than  any  of  the  other 
preparations,  as  it  does  not  disagree  with  the  stomach. 

In  many  cases,  however,  after  a  time  the  intestinal  canal  loses 
its  power  of  absorption,  and  the  mercury  is  eliminated  with  the  f feces 
without  having  passed  through  the  blood.  On  this  account  it  is 
always  desirable  to  stop  the  internal  administration  of  mercury,  after 
six  or  eight  months,  in  order  to  allow  the  intestinal  tract  to  rest,  and 
during  the  interim  several  courses  of  inunctions  should  be  made. 

At  the  end  of  the  first  twelve  months,  unless  some  indication 
appears  for  it  earlier,  the  administration  of  iodide  of  potash  is  begun, 


1 


ioy^  rv-4itAtfwnsaa 


THERAPEUTICS  OF  SYPHILIS.  335 

and  the  mercury  is  continued  in  addition.  A  favorite  and  useful  pre- 
scription which,  although  chemically  incompatible,  is  therapeutically 
active,  is  the  following  for  the  so-called  mixed  treatment: — 

IJ  Hydiargyri  bichloridi o-r.  ij. 

Potassii  iodidi 3v. 

Syrupus  sarsaparillse fgij. 

Aquae  destillatse q.  s.  ad  fsiv. 

M.     Sig.:    3j  t.  i.  d. 

The  iodide  of  potash  has  no  direct  action  on  the  virus  of  syph- 
ilis, but  it  stimulates  the  activity  of  the  lymphatic  system,  facilitates" 
getting  rid  of  waste-products,  and  also  causes  the  absorption  of  any 
syphilitic  infiltration  which  may  have  taken  place  in  the  tissues  or 
arteries. 

The  iodide  of  potash  and  mercury  should  be  continued  together 
with  an  intermission  every  six  months,  during  which  courses  of  inunc- 
tions should  be  made.  At  the  end  of  two  and  one-half  years'  treat- 
ment the  patient  having  been  on  mercury  alone  for  twelve  months 
and  mercury  and  iodide  of  potash  together  eighteen  months  longer, 
the  medication  may  be  stopped. 

The  patient  should  be  then  kept  under  observation  six  months 
more,  and,  if  no  relapses  occur,  the  syphilis  may  be  considered  at  an 
end. 

The  general  nutrition  of  the  patient  should  receive  the  closest 
attention  during  this  protracted  treatment.  Syphilis  itself  is  a  de- 
bilitating disease,  and  mercury,  if  administered  for  a  long  time,  has 
the  effect  of  causing  a  condition  of  pallor  and  anasmia.  Of  course, 
when  such  an  effect  is  induced,  the  mercury  should  be  stopped  and 
tonics  given. 

Tonics  are  usually  required  at  some  stage  in  the  disease,  to  coun- 
teract the  destruction  of  red  corpuscles  caused  by  the  virus.  The 
ana?mia  is  treated  with  iron,  and  the  nervous  system  and  general  nu- 
trition are  stimulated  with  strychnia.  Codliver-oil  is  very  valuable 
for  the  emaciation  and  loss  of  weight,  and  especially  so  if  there  is  a 
complication  of  tuberculosis.  Close  attention  should  also  be  paid  to 
the  matters  of  fresh  air,  exercise,  food,  sleep,  and  freedom  from 
anxiety. 

Severe  Form  of  Syphilis. — The  severe  cases  of  syphilis  and  malig- 
nant syphilis  cannot  be  treated  in  any  routine  way,  but  each  case  must 
be  handled  with  reference  to  its  own  peculiarities.    We  can  say,  in  a 


336  SYPHILIS  AND  ITS  LESIONS. 

general  way,  that  it  is  necessary  to  get  the  patient  promptly  under  the 
influence  of  mercury  and  at  the  same  time  avoid  disturbing  the  diges- 
tion, and  the  hygienic  treatment — consisting  in  good  food,  good  hy- 
gienic surroundings,  sunlight,  fresh  air,  and  tonics — is  imperatively 
demanded  in  these  cases. 

The  best  method  of  using  mercury  is  by  inunction,  and  next  in 
value  may  be  ranked  the  hypodermic  injections.  The  disadvantages 
of  giving  mercury  by  the  mouth  are  that  it  acts  more  slowly  and  is 
very  apt  to  disturb  the  digestion.  After  the  disease  is  under  control 
the  mercury  may  be  given  by  the  mouth,  but  inunctions  should  be 
used  a  couple  of  times  a  year. 

In  this  class  of  cases  it  is  necessary  to  begin  the  administration 
of  iodide  of  potash  earlier  than  at  the  beginning  of  the  second  year, 
inasmuch  as  tertiary  lesions  or  gummata  are  apt  to  occur  precociously, 
even  as  early  as  the  fifth  or  six  month,  and  the  iodide  generally  has 
to  be  used  in  larger  doses. 

After  the  syphilis  has  run  a  severe  course  for  a  few  months  a  con- 
dition is  induced  which  is  known  as  the  cachexia  of  syphilis,  and 
which  is  characterized  by  extreme  debility  and  vital  depression,  which 
have  resulted  in  consequence  of  the  anaemia  and  emaciation. 

If  severe  spreading  lesions  exist  upon  the  skin  and  mucous  mem- 
branes, the  case  may  be  properly  termed  malignant  syphilis.  These 
patients  unfortunately  do  not  bear  mercury  and  the  iodide  well,  and 
in  these  conditions  such  tonic  remedies  as  Zittmann's  decoction  and 
the  hot  springs  of  Arkansas  are  to  be  recommended. 

Grave  tertiary  lesions  of  the  viscera  or  nervous  system  are  liable 
to  follow  a  mild  attack  as  well  as  a  severe  one,  and,  of  course,  the  out- 
look for  ultimate  recovery  depends  largely  upon  the  general  character 
of  the  patient's  constitution. 

With  individuals  of  fair  bodily  health,  in  the  presence  of  a 
gumma  of  the  brain  or  viscera,  or  of  endarteritis  of  the  arteries  sup- 
plying the  nervous  system,  or,  indeed,  any  of  the  manifold  complica- 
tions of  the  tertiary  period,  the  mercury  should  be  given  by  inunction 
and  iodide  of  potash  in  saturated  solution.  The  dosage  of  the  iodide 
should  be  increased  rapidly  up  to  ^/o  ounce  or  even  1  ounce  in  the 
day,  the  only  rule  for  the  quantity  given  being  the  effect  produced. 


LOCAL  TREATMENT  OF  LESIONS.  337 

LOCAL  TREATMENT  OF  LESIONS. 

It  has  been  found  that  the  direct  contact  of  a  mercurial  prepara- 
tion with  a  local  syphilitic  lesion  hastens  its  disappearance  by  absorp- 
tion. An  advantage  is  sometimes  taken  of  this  fact  by  using  fumiga- 
tion or  bichloride  baths,  in  addition  to  the  regular  general  treatment, 
to  accelerate  the  healing  of  extensive,  wide-spread,  ulcerating  lesions 
of  the  skin. 

The  papular  eruptions  on  the  face  are  annoying  and  unsightly, 
and  can  be  made  to  clear  up  more  quickly  by  rubbing  in  one  of  the 
following  ointments: — 

Oleate  of  mercury,  5  per  cent. 
White-precipitate  ointment. 
Mercurial  plaster. 

Mucous  Patches. — If  mucous  patches  exist  in  the  mouth,  they 
are  always  of  danger  to  innocent  people,  since  their  secretions  may  be 
conveyed  upon  some  utensil  and  be  inoculated  into  another  person. 
On  this  account  we  should  endeavor  to  heal  them  as  quickly  as  pos- 
sible. In  addition  to  the  frequent  use,  by  the  patient,  of  a  mouth-wash 
of  chlorate  of  potash  or  calomel  and  lime-water,  the  patches  them- 
selves should  be  touched  every  three  or  four  days  with  nitrate  of  silver 
in  stick,  or  glycerin  and  carbolic  acid  in  equal  parts,  bichloride  of  m.er- 
cury  in  alcohol  (1  in  20),  or  the  acid  nitrate  of  mercury. 

Condylomata  heal  readily  under  the  general  mercurial  treatment, 
and  it  is  only  necessary  to  keep  them  clean;  cover  them  with  a  dust- 
ing-powder, which  absorbs  their  secretions;  and  prevent  contact  with 
other  parts  and  chafing  by  means  of  absorbent  cotton  interposed. 


CHAPTER    XXIII. 

INHERITED  SYPHILIS. 

As  ALREADY  stated  in  the  last  chapter,  the  parental  syphilis 
exerts  a  bad  effect  upon  the  foetus,  unless  a  degree  of  immunity  has 
been  induced.  In  its  most  active  stages  the  effect  of  the  poison  is  to 
cause  the  termination  of  the  pregnancy  in  an  abortion;  that,  as  the 
syphilis  grows  older  its  virulence  lessens,  so  that  the  next  child  is 
probably  still-born,  and  the  following  one  may  be  born  alive,  but  with 
the  syphilitic  taint. 

Children  which  are  still-born  are  usually  retained  long  enough  in 
the  uterus,  after  death,  to  become  macerated.  The  epidermis  is 
stripped  off  or  raised  up  into  large  bullae.  The  liquor  amnii  is  dis- 
colored, brown,  and  foul-smelling.  On  examination  of  the  infant's 
viscera,  upon  the  autopsy-table,  they  are  found  to  be  the  seat  of  the 
characteristic  changes  of  syphilis. 

Occasionally  children  are  born  of  syphilitic  parents  who  have  all 
the  manifestations  of  a  florid  syphilis  upon  them,  but  usually  one  or 
two  weeks  pass  before  the  syphilis  becomes  visible.  In  appearance 
these  children  are  usually  ill  developed,  small,  and  of  light  weight. 
The  skin  is  faded,  and  they  look  like  little,  shriveled,  old  men. 

If  the  parental  syphilis  is  still  older,  the  children  may  be  born 
apparently  healthy,  and  develop  syphilitic  manifestations  later.  The 
most  common  time  for  their  appearance  is  within  the  first  three 
months  after  birth  and  rarely  later  than  the  first  six  months. 

Although  children  born  of  syphilitic  parents  may  escape  the  in- 
heritance of  an  active  form  of  syphilis  by  reason  of  a  certain  acquired 
immunity,  they  may  receive  a  diathetic  taint,  which  does  not  make 
itself  evident  by  any  characteristic  manifestations.  These  children 
have  a  feeble  constitution,  and  suffer  from  a  general  want  of  mental 
and  bodily  development  which  is  particularly  notable  at  the  time  of 
puberty. 

The  children  develop  slowly,  remain  small,  and  are  thin  and 
ana?mic  and  without  the  power  of  resistance  against  accidental  disease. 
The  intelligence  is  often  deficient,  and  such  instances  are  described  as 
cases  of  late  hereditary  syphilis. 
(338) 


INHERITED  SYPHILIS. 


339 


COURSE. 

The  course  of  iziherited  syphilis  resembles  that  of  the  acquired 
disease,  except  that  it  does  not  begin  from  a  chancre  and  that  the 
lesions  peculiar  to  the  secondary  and  tertiary  periods  appear  simul- 
taneously. 

When  a  child  is  born  apparently  well,  but  develops  syphilis  later, 
one  of  the  most  striking  symptoms  of  the  impending  outbreak  is  the 
nasal  catarrh,  causing  snuffles.  This  is  soon  followed  by  an  affection 
of  the  mucous  membrane  of  the  mouth  and  larynx,  which  causes  a 
hoarse  cry.  Mucous  patches  occur  about  the  skin  of  the  mouth,  which 
interfere  with  the  child's  nursing,  and  the  nutrition  suffers. 

The  eruptions  upon  the  skin  resemble  those  of  acquired  syphilis. 
A  macular  eruption  often  occurs  upon  the  chest,  and  a  diffused  ery- 
thematous redness,  resembling  eczema  in  outward  appearances,  is  often 
seen  about  the  mouth  and  navel  and  parts  where  the  skin  is  liable  to 
chafe  against  another  opposing  surface,  such  as  in  the  groins,  axillae, 
or  nates. 

If  the  patient  is  not  treated,  and  in  severe  cases,  the  eruption  de- 
velops into  papules.  The  soles  of  the  feet  and  palms  of  the  hands 
become  the  seat  of  copper-colored  papules,  which  desquamate  and  are 
changed  into  deep  fissures.  The  papules  located  about  the  mouth, 
anus,  and  genitals  are  apt  to  become  transformed  into  luxuriant  and 
vegetating  condylomata. 

An  eruption  which  is  unique,  inasmuch  as  it  does  not  occur  in 
adults,  but  only  in  children,  is  syphilitic  pemphigus,  in  which  large 
hullce,  or  blebs,  form  on  the  palms  and  soles,  although  it  sometimes 
occurs  over  the  entire  body.  Its  formation  is  explained  by  the  delicate 
character  of  the  epidermis  and  the  readiness  with  which  serum  collects 
underneath  it  and  raises  it  from  the  derma,  forming  a  vesicle,  or  bulla. 

All  the  above-mentioned  eruptions  may  exist  at  the  same  time, 
and  the  symptom  of  polymorphism  is  usually  more  marked  in  inherited 
than  in  acquired  syphilis. 

The  viscera  are  affected  in  inherited  syphilis  even  more  fre- 
quently than  in  the  acquired  form.  The  liver  is  often  the  seat  of  a 
form  of  cirrhosis  occasioned  by  its  infiltration  with  newly-formed  con- 
nective tissue,  or  gummata  may  exist  in  various  portions  of  the  gland. 
The  pancreas  is  affected  in  a  similar  way.  The  lungs  may  be  the  site 
of  gummata,  and,  as  a  consequence  of  periarteritis,  the  frame-work 
of  the  alveoli  becomes  infiltrated  with  new  cells  in  various  areas, 
causing  white  hepatization. 


340  SYPHILIS  AND  ITS  LESIONS. 

A  very  characteristic  feature  of  inherited  syphilis  is  osteochon- 
dritis, which  is  considered  by  some  authorities  as  patliognombnic.  It 
consists  in  an  overgrowth  of  the  cartilage  which  is  interposed  between 
the  epiphyses  and  the  diaphyses  of  the  long  bones  and  skull.  By 
palpation  the  enlarged  cartilage  can  ue  felt  surrounding  the  bone  like 
a  collar.  The  ultimate  course  of  the  inflammation  may  end  in  sup- 
puration and  necrosis,  and,  after  extrusion  of  the  dead  bone,  the  in- 
jury is  repaired  by  the  abundant  formation  of  new  bony  tissue, 
causing  an  osteophyte.  Osteophytes  occurring  upon  the  skull  give  a 
peculiar  "squared"  shape  to  it. 

The  inflammation  involving  the  cartilages  often  travels  to  the 
joints,  and  a  serous  or  purulent  synovitis  occurs.  The  teeth  of  the 
second  set  are  deformed  by  a  vertical  notching  and  peg  shape  of  the 
central  incisors. 

The  nervous  system  suffers  as  well,  and  epileptiform  convulsions, 
tabes,  and  progressive  paral3^sis  are  frequently  seen  in  syphilitic  chil- 
dren. 

Hsemorrhagic  syphilis  exists  at  birth  or  else  makes  its  appearance 
within  the  first  month.  It  is  a  condition  in  which  the  blood  is  effused 
under  the  skin  or  mucous  membranes,  forming  large  purpuric  spots. 
It  is  not  infrequently  met  with,  and  is  due  to  the  endarteritis,  which 
permits  the  escape  of  blood  in  greater  or  less  quantities. 


RECOGNITION  OF  INHERITED  TAINT. 

There  are  certain  points  W'hich  are  of  use  in  making  a  diagnosis 
of  inherited  syphilis  at  an  age  advanced  from  infancy.  The  most 
reliable  sign  is  the  presence  of  Hutchinson's  teeth.  The  central  upper 
incisors  of  the  second  set  are  the  most  characteristically  affected. 
The  deformity  consists  in  the  peg  shape  of  the  teeth  and  the  vertical 
notcMng  in  their  loiver  edges.  Jonathan  Hutchinson  considers  them 
pathognomonic  of  inherited  syphilis,  and  describes  them  as  follows: 
"The  central  incisors  are  short  and  narrow,  with  a  broad  vertical 
notch  on  their  edges  and  their  corners  rounded  off.  Horizontal 
notches  or  furrows  are  often  seen,  but,  as  a  rule,  have  nothing  to  do 
with  syphilis." 

In  the  subjects  of  inherited  syphilis  the  sTcin  is  thick,  pasty,  and 
opaque,  or  occasionally  remarkably  soft  and  silky.  At  the  angles  of 
the  mouth  may  sometimes  be  noticed  linear  scars,  radiating  out  into 
the  cheeks.     The  hridge  of  the  nose  is  usually  broad  and  low,  and  a 


Fig.  94.^ — Hutcliinson's  Teeth.  These  Teeth  have  been  recently 
cut,  and  the  Central  Notch  is  well  outlined,  but  the  thin  and  un- 
protected dentine  has  not  j^et  crumbled  away. 


Fiff.  95. 


Fig.  96. 

Figs.  95  and  96  Show  Later  Stages  of  the  Process  after  the  Den- 
tine has  been  destroyed.  The  characteristic  Peg  shape,  with  the 
vertical  Central  Notch,  is  clearly  shown. 


(341) 


INHERITED  SYPHILIS. 


343 


rant  of  firmness  in  tlie  cartilaginous  septum,  which  allows  the  nose 
to  be  shaken  about  too  easily,  is  sometimes  observed. 

The  eyes  are  liable  to  be  affected,  and  the  occurrence  of  a  well- 
marked  interstitial  keratitis  is  regarded  as  pathognomonic  of  inherited 
syphilis.  The  skull  is  apt  to  be  squared  in  shape  and  to  show  low 
protuberances  in  various  parts.  The  long  hones  are  often  the  seat  of 
periosteal  thickenings  or  nodes,  and  the  phalanges  and  neighboring 
joints  may  be  affected  by  a  globular  swelling,  a  form  of  periostitis  or 
ostitis,  to  which  the  name  dactylitis  is  given. 

The  ears  are  occasionally  affected,  and  symmetrical  deafness, 
which  has  occurred  without  discharge  from  the  ears,  is  said  to  be 
strong  corroborative  evidence  of  an  inherited  taint. 

TREATMENT. 

It  has  been  thought  possible  to  treat  an  infant,  affected  with 
syphilis,  by  giving  mercury  to  the  mother,  and  allowing  the  child  to 
nurse  from  her  breast.  It  was  supposed  that  enough  mercury  would 
be  eliminated  in  the  Inilk  to  control  the  syphilis  of  the  child.  The 
quantity,  however,  eliminated  in  the  milk  is  too  small  to  be  of  very 
much  avail,  and  we  are  obliged  to  give  specific  treatment  in  other 
ways. 

With  children,  as  in  the  case  of  adults,  inunctions  are  the  most 
useful  way  of  giving  mercury,  as  in  this  way.  the  digestion  is  not 
interfered  with. 

It  is  not  necessary  to  rub  the  ointment  all  over  the  body,  as  in 
adults,  but  30  grains  of  mercurial  ointment,  mixed  with  an  equal 
quantity  of  lanolin  to  assist  absorption,  may  be  spread  on  the  child's 
binder,  which  surrounds  the  abdomen,  and  allowed  to  remain  in  con- 
tact with  the  skin  for  two  or  three  days.  At  the  end  of  that  time  the 
ointment  may  be  renewed. 

If  too  much  irritation  is  caused  and  an  eczema  follows,  the  inunc- 
tions must  be  suspended  and  the  drug  given  by  the  mouth.  Various 
preparations  of  mercury  may  be  used  in  this  way. 

Among  those  most  highly  recommended  are  the  following: — 

IJ  Hydrargj^ri  cum  cretse gr.  i-vj. 

Sacchari  albi gr.  xij. 

M.  et  div.  in  ehartulas  xij. 
Sig. :    One  t.  i.  d. 

I^  Calomel gr.  '/*-'/,. 

Big.:    Three  times  a  day. 


344  SYPHILIS  AND  ITS  LESIONS. 

IJ  Bichloride  of  mercury gr.  Voa-Vw 

Sig.:    Three  times  a  day. 

As  we  have  already  found,  in  infantile  syphilis  the  division  into 
secondary  and  tertiary  periods  is  not  clearly  defined,  and  the  lesions 
peculiar  to  both  periods  often  exist  at  the  same  time.  On  this  account 
iodide  of  potash  is  often  called  for  by  the  appearance  of  tertiary  lesions 
at  an  early  date  in  the  course  of  the  disease.  Iodide  of  potash  may 
be  given  in  doses  of  gr.  j  three  times  a  day,  or  it  may  be  necessary  to 
give  it  in  much  larger  doses,  if  the  lesions  are  severe. 

It  is  eminently  desirable  to  maintain  the  nutrition  of  a  syphilitic 
child,  and  this  can  best  be  accomplished  by  allowing  it  to  nurse  from 
its  own  mother.  The  various  forms  of  artificial  feeding  are  less  useful, 
and  should  only  be  resorted  to  when  the  mother's  milk  is  insufficient. 

Duration  of  Treatment. — No  definite  rules  can  be  laid  down  for 
the  length  of  time  required  for  the  treatment.  It  is  considered  best  to 
continue  for  at  least  two  years,  with  occasional  intermissions,  but 
treatment  should  only  be  stopped  after  all  manifestations  have  ceased. 


IMPOTENCE  AND  STERILITY. 


CHAPTER   XXIV. 

IMPOTENCE. 

Impotence  may  be  defined  as  an  inability  on  the  part  of  the  male 
to  copulate,  either  on  account  of  a  failure  of  the  penis  to  become  erect 
or  because  the  ejaculation  of  seminal  fluid  takes  place  prematurely 
and  before  the  penis  has  entered  the  vagina  or  else  does  not  occur  at 
all. 

The  mechanism  of  copulation  is  a  complicated  one,  and  requires 
for  its  performance  the  co-ordinated  working  of  both  nervous  and 
muscular  systems.  The  function  of  erection  is  known  to  be  under 
the  control  of  a  collection  of  nervous  ganglia  situated  in  the  lumbar 
enlargement  of  the  spinal  cord,  which  is  called  the  centre  of  erection. 
The  centre  of  erection  receives  nerve-filaments  from  the  genital  cen- 
tre in  the  brain,  and  it  also  receives  sensory  fibres  from  the  rectum, 
bladder,  and  genitals.  It  also  sends  out  nerves,  the  nervi  erigentes, 
to  the  genitals,  whose  function  is  to  cause  a  vasomotor  paresis  of  the 
blood-vessels  in  the  corpora  cavernosa. 

A  knowledge  of  the  distribution  of  these  various  nerves  serves 
to  explain  the  following  facts:  An  erection  may  be  provoked  by  the 
influence  of  the  brain,  if  it  entertains  libidinous  ideas,  or  an  inhibitory 
influence  may  be  exerted  from  the  brain  by  the  mental  emotions  of 
fear,  disgust,  or  fright  (psychical  impotence),  and  vigorous  mental 
activity  has  the  effect  of  removing,  for  the  time  being,  sexual  desire. 

Certain  forms  of  irritation  of  the  spinal  cord,  caused  by  myelitis, 
traumatism,  or  fracture-dislocation,  when  the  lesion  is  located  in  the 
cervical  or  upper  dorsal  region,  are  often  attended  with  persistent  and 
powerful  erections  of  the  penis. 

Erections  are  also  caused  by  peripheral  irritation  from  the  gen- 
itals, transmitted  along  the  nerves  leading  to  the  centre  of  erection 
in  the  cord.  At  this  point,  as  a  result  of  irritation  of  the  genitals, 
the  sensory  impulse  is  converted  into  a  motor  one  and  reflected  back 
again  to  the  genitals  along  the  7iervi  erigentes. 

As  common  illustrations  of  erections  from  peripheral  irritation 
may  be  mentioned  the  erections  occasioned  by  a  bladder  filled  with 

23  (345) 


346  IMPOTENCE  AND  STERILITY. 

urine  in  the  morning,  prostatic  enlargement,  or  the  passage  of  a  sound 
through  the  deep  urethra. 

MECHANISM  OF  ERECTION, 

The  mechanism  of  erection  is  as  follows:  Under  the  influence  of 
the  nervi  erigentes  a  relaxation  of  the  vascular  spaces  in  the  corpora 
cavernosa  takes  place,  and  they  fill  with  blood.  The  penis  becomes 
erect,  hard,  and  elongated,  because  the  blood  is  pumped  into  the 
spaces  and  retained  there. 

If  the  blood  flowed  out  of  the  erectile  tissue  as  fast  as  it  came  in, 
erection  could  not  occur,  but  the  swelling  of  the  corpora  cavernosa 
exerts  a  certain  degree  of  pressure  upon  the  veins  which  ordinarily 
conduct  the  outflowing  blood  away  from  the  penis.  The  return-flow 
of  blood  is  checked  by  the  pressure  on  the  veins,  and  it  is  retained  in 
the  spaces  of  the  erectile  tissue  of  the  penis. 

Unless  the  spaces  of  the  erectile  tissue  be  completely  relaxed,  a 
sufficient  quantity  of  blood  cannot  enter  them  to  exert  pressure  on 
the  outgoing  veins,  and  the  blood  flows  away  through  them. 

MECHANISM  OF  EJACULATION. 

In  a  normal  condition  ejaculation  only  occurs  with  a  fully  erect 
penis,  except  during  sleep. 

As  the  spaces  of  the  corpora  cavernosa  become  filled  with  blood, 
the  verumontanum,  or  caput  gallinagiuis,  which  is  composed  of 
erectile  tissue,  also  swells  and  becomes  erect,  thus  blocking  the  en- 
trance to  the  bladder,  so  that  urine  cannot  flow  out. 

The  urethral  glands  secrete  freely  and  a  viscid  clear  drop  of 
mucus  appears  at  the  orifice  of  the  urethra.  The  object  of  the  secre- 
tion is  to  cover  the  urethral  walls  bathed  in  acid  urine  and  to  prepare 
them  for  the  reception  of  the  semen. 

The  contents  of  the  seminal  vesicles  are  poured  out  through  tlie 
ejaculatory  ducts  until  the  posterior  and  bulbous  dilatations  of  the 
urethra  become  filled  with  semen,  and  after  these  are  distended  con- 
tractions of  the  bulbo-cavernosus  muscles  occur,  and  the  semen  is 
ejaculated  in  jets  from  the  meatus.  If  the  force  of  the  muscles  is 
impaired,  as  in  paralytic  impotence,  the  semen  is  not  shot  out  in  jets, 
but  dribbles  slowly  away  from  the  meatus. 

CLASSIFICATION  OF  FORMS  OF  IMPOTENCE. 

I.  Organic,  from  mechanical  defects. 

II.  Psychical,  or  imaginary:     1.  Complete.     2.  Kelative, 


ORGANIC  IMPOTENCE.  347 

III.  Atonic,  from  exhaustion  of  genital  centres  in  brain  and 
spinal  cord. 

IV.  Symptomatic:  Variety  A.  Irritable  Impotence,  from  disease 
in  urethra  or  adnexa.  Variety  B.  Paralytic  Impotence,  from  organic 
disease  in  nervous  system.     Variety  C.  Impotence  due  to  Drugs. 


ORGANIC  IMPOTENCE. 

In  this  form  of  impotence  some  physical  cause,  which  is  either 
congenital  or  acquired,  renders  coitus  mechanically  impossible.  The 
obstacle  may  prevent  the  introduction  of  the  penis  into  the  vagina, 
or,  in  the  absence  of  a  urethra  while  coitus  can  be  performed,  it  is  not 
possible  to  inject  the  semen  into  the  vagina. 

Among  the  causes  of  organic  impotence  may  be  mentioned  such 
failures  of  development  as  hypospadias,  epispadias,  small  size  of  the 
organ,  or  acquired  deformities  (such  as  elephantiasis  and  tumors),  dis- 
ease of  the  corpora  cavernosa  (such  as  syphilitic  or  fibroid  induration), 
or  partial  destruction  following  wounds,  and  cavernitis  are  sometimes 
responsible  for  interference  with  coitus,  and  operate  by  causing  a 
deviation  or  curve  in  the  penis  upon  erection.  ' 

Swellings  of  the  surrounding  parts,  such  as  hernia,  scrotal  tu- 
mors, or  excessive  corpulence,  with  an  overhanging  belly,  may  render 
insertion  of  the  penis  impossible,  but  the  sexual  desire  is  strong,  and 
ejaculation  occurs. 

TREATMENT. 

In  organic  impotence  the  treatment  will  be  successful  in  so  far 
as  it  is  possible  to  remove  the  mechanical  obstacle  to  copulation. 

In  hypospadias  and  epispadias  a  plastic  operation  can  be  per- 
formed, and,  when  the  penis  is  completely  inclosed  by  overlying  tis- 
sues, a  small,  freely-movable  penis  capable  of  intromission  may  be 
formed. 

Tumors  and  elephantiasic  growths  must  be  removed  by  surgical 
means,  and  hernia  and  hydrocele  also  call  for  operation.  An  effort 
should  be  made  to  bring  about  absorption  of  the  infiltration  in  the 
corpus  spongiosum,  which  may  be  confidently  expected  to  occur  if  it 
is  syphilitic  in  origin. 


348  IMPOTENCE  AND  STERILITY. 


PSYCHICAL  IMPOTENCE. 


"We  have  already  noted  in  studying  the  physiology  of  coitus,  the 
fact  that  the  brain  is  capable  of  exerting  a  restraining  influence  over 
the  power  of  erection,  through  the  inhibitory  nerves  which  go  to  the 
spinal  centre  of  erection.  As  a  result  of  nervous  excitement,  the 
action  of  the  inhibitory  nerves  from  the  brain  is  aggravated,  and 
erection  fails  at  the  critical  moment.  The  influence  of  fear  and 
dread  are  observed  in  the  same  class  of  patients  before  passing  a  sound. 

When  these  individuals  are  lying  on  the  table,  the  penis  is  seen 
to  shrink  and  grow  smaller  and  move  in  a  worm-like  manner,  which 
is  caused  by  the  spasmodic  contraction  of  the  muscular  fibres  im- 
bedded in  the  trabeculse  of  the  corpora  cavernosa.  In  such  cases  the 
inhibitory  nerves  are  stimulated  by  the  dread  of  catheterism,  and  in 
the  same  way  other  psychical  influences  stimulate  the  action  of  the 
inhibitory  nerves,  and  the  patient  is  at  such  moments  impotent. 

Various  types  of  men  are  affected  by  the  form  of  psychical,  or 
imaginary,  impotence,  as  follows: — 

Class  A. — A  few  strong,  young,  vigorous  men  who  have  lead 
clean  lives,  on  being  married  to  the  women  of  their  choice,  either 
from  a  state  of  nervous  excitement  or  a  lack  of  confidence  in  them- 
selves or  perhaps  occasionally  from  timidity  and  bashfulness,  do  not 
succeed  in  holding  an  erection  long  enough  to  perform  coitus,  and  the 
erection  either  fails  to  be  complete  or  else  ejaculation  occurs  prema- 
turely. 

Class  B. — Feeble,  despondent,  oversensitive  individuals  of  weak 
nervous  fibre,  who  have  masturbated,  had  an  attack  of  gonorrhoea,  or 
have  been  excessive  in  sexual  intercourse.  Such  persons  are  contin- 
ually dwelling  on  past  abuse  and  worrying  over  trifling  symptoms, 
such  as  a  varicocele  or  the  normal  weekly  occurrence  of  a  seminal 
emission,  and  their  fears  are  aggravated  by  reading  quack  books. 

Class  C. — Men  of  good  health  and  well-balanced  minds  may  be 
affected  by  various  mental  emotions,  such  as  fear,  disgust,  and  loath- 
ing, or  the  departure  from  regular  habit,  all  of  which  may  induce 
temporary  impotence. 

It  is  no  uncommon  experience,  when  illicit  intercourse  is  being 
attempted,  that  a  fear  of  exposure  or  infection  or  of  disgust  at  some 
coarse  remark  on  the  part  of  the  woman  causes  a  failure  or  sudden 
subsidence  of  the  erection. 


PSYCHICAL  IMPOTENCE.  349 

The  effect  of  habit  is  seen  in  the  cases  where  a  man  is  accustomed 
to  cohabit  successfully  with  one  woman,  but  fails  to  accomplish  the 
act  of  coitus  with  a  stranger,  until  he  becomes  accustomed  to  the  new 
fields.  Eoubaud's  case  is  cited  as  an  example  of  this.  A  young  man 
who  was  accustomed  from  the  beginning  of  his  sexual  life  to  a  certain 
type  of  woman,  who  was  a  blonde  and  always  met  him  dressed  in  a  silk 
gown  and  with  shoes  on,  could  never  have  coitus  with  any  other 
woman,  unless  she  were  also  a  blonde  and  dressed  in  a  similar  manner. 

Severe  and  prolonged  mental  strain,  such  as  occurs  with  students 
and  business  and  professional  men,  sometimes  brings  about  a  condi- 
tion of  general  neurasthenia,  one  of  the  syinptoms  of  which  is  tem- 
porary impotence. 

Relative  impotence  is  a  form  of  psychical  impotence,  and  is  the 
term  applied  to  a  condition  in  which  the  man  is  able  to  copulate  with 
certain  women  only,  and  not  with  others. 

When  this  is  the  case  between  man  and  wife,  it  may  be  due  to 
a  mutual  aversion  or  a  lack  of  sexual  feeling  on  the  part  of  the  wife, 
which  reacts  upon  the  man  and  takes  away  his  desire,  and  yet  the  same 
man  may  be  entirely  potent  with  other  women. 


TREATMENT. 

Before  beginning  treatment,  it  is  essential  to  make  sure  that  we 
are  dealing  with  a  case  of  true  psychical  impotence  and  that  the  im- 
potence is  not  symptomatic  of  some  lesion  in  the  urethra  or  nervous 
system. 

The  psychical  form  disappears  spontaneously  when  the  mental 
disturbances  occasioning  it  vanish.  For  instance,  the  death  of  a 
beloved  wife  or  loss  of  fortune  and  business  anxieties  may  cause  tem- 
porary impotence,  which  disappears  as  time  goes  by  or  the  individual's 
circumstances  improve.  In  these  cases  the  friendly  advice  of  a  phy- 
sician in  whom  the  patient  has  confidence  is  valuable. 

The  largest  number  of  cases  of  psychical  impotence  occur  in  nerv- 
ous young  men  who  have  had  gonorrhoea  or  masturbated  freely,  and 
who  have  read  and  pondered  over  the  false  and  lurid  accounts  in 
quack  medical  advertisements,  pretending  to  describe  the  evil  con- 
sequences of  masturbation  or  sexual  excesses. 


350  IMPOTENCE  AND  STERILITY. 

ATONIC  IMPOTENCE. 

The  term  atonic  impotence  has  been  rather  loosely  used  by  au- 
thors, and  has  been  incorrectly  made  to  include  cases  which  were 
dependent  upon  lesions  of  the  urethra  or  spinal  cord  or  the  abuse  of 
drugs,  and  should  have  been  properly  classed  under  the  head  of 
symptomatic  impotence. 

Atonic  impotence  is  a  variety  of  comparatively  rare  occurrence, 
and  in  which  there  is  no  demonstrable  lesion  of  the  nervous  system 
or  urethra.  It  is  purely  functional  in  character,  and  is  dependent 
entirely  upon  a  failure  of  the  spinal  centre  of  erection,  and  perhaps 
the  genital  centre  in  the  brain,  to  respond  to  ordinary  stimuli  and 
cause  the  penis  to  become  erect. 

It  should  be  borne  in  mind,  however,  that  a  condition  of  ex- 
haustion of  the  nerve-centres  is  often  complicated  by  chronic  inflam- 
matory changes  in  the  posterior  urethra,  induced  by  a  gonorrhoea  of 
long  standing  or  sexual  abuses,  and  this  fact  should  not  be  lost  sight 
of  in  carrying  out  the  treatment.  Here,  again,  advice  and  the  assur- 
ances of  the  physician,  in  combination  with  attention  to  building  up 
the  general  health  by  salt-water  bathing,  out-of-door  exercise,  boating, 
golf,  and  moderate  walking  or  light  gymnastic  exercises  is  the  basis 
of  treatment. 

Hypnotism  may  be  successful  in  relieving  this  form  of  impotence, 
but,  as  our  knowledge  of  influencing  the  mental  powers  in  this  way 
becomes  more  extended,  the  danger  of  inducing  the  hypnotic  state  and 
other  drawbacks  becomes  more  obvious;  so  that,  in  general,  it  is  not 
desirable  to  employ  this  form  of  treatment. 

In  atonic  impotence  sexual  desire  is  often  present,  but  frequently 
it  is  absent,  and,  as  a  rule,  erections  do  not  occur  at  all.  Sometimes, 
however,  in  mild  cases,  a  partial  erection,  accompanied  by  premature 
ejaculation  of  semen,  takes  place. 

The  atonic  form  of  impotence  is  exclusively  found  in  married 
men  who  have  practiced  coitus  excessively  or  "withdrawal"  with  their 
wives  for  years,  excessive  masturbators,  and  old  I'oues  whose  only 
thought  in  life  has  been  the  gratification  of  their  sexual  desires. 

The  lack  of  erectile  power  is  usually  only  one  s3'mptom  of  general 
neurasthenia,  which  is  accompanied  by  its  usual  signs,  viz.:  mental 
symptoms  such  as  impairment  of  memory,  fullness  in  the  head,  and 
anxiety;  pains  in  the  back  and  limbs,  feeble  heart-action,  vasomotor 
disturbances,  indigestion,  constipation,  etc. 


ATONIC  IMrOTENCE.  35 ;i 

These  general  symptoms  have  been  described  by  quacks  in  terri- 
fying terms,  in  pamphlets  pretending  to  set  forth  the  "evil  effects  of 
self-abuse,'-  which  have  an  extensive  circulation  among  the  laity. 

Authorities  are  now  generally  agreed  that,  aside  from  a  degrada- 
tion of  the  moral  character  of  the  individual,  masturbation,  practiced 
occasionally,  exercises  but  little  bad  effect  upon  the  general  health, 
and  its  effects  cease  as  soon  as  the  habit  is  stopped,  unless  a  condition 
of  chronic  inflammation  is  induced  in  the  posterior  urethra,  and  the 
same  is  true  of  coitus  reservatus,  or  withdrawal. 

If,  however,  masturbation  or  withdrawal  is  practiced  at  frequent 
intervals  and  for  a  long  period  of  time,  chronic  posterior  urethritis 
occurs,  which  gives  rise  to  various  local  symptoms  and  is  often  com- 
plicated by  a  general  neurasthenic  state  (see  "Chronic  Posterior  Ure- 
thritis"). 

DIAGNOSIS  AND  TREATMENT. 

Before  making  a  diagnosis  of  atonic  impotence  care  should  be 
taken  to  exclude  any  disease  of  the  urethra  and  its  adnexa  or  the 
nervous  system.  It  is  generally  the  case  that,  with  old  rounders  and 
masturbators,  a  stricture,  chronic  urethritis,  prostatitis,  seminal 
vesiculitis,  or  beginning  spinal  disease  is  present,  and  the  impotence 
is  not  atonic  and  caused  by  exhaustion  of  the  nervous  centres,  but  is 
secondary  to  and  a  symptom  of  the  local  structural  change  in  urethra 
or  spinal  cord. 

When  all  these  local  conditions  have  been  excluded,  however,  and 
we  are  certain  that  we  are  dealing  with  a  pure  functional  neurosis,  the 
following  lines  of  treatment  may  be  employed: — 

The  indications  are  to  build  up  the  general  health  of  the  patient, 
and  at  the  same  time  give  complete  rest  to  the  genital  centres  in  the 
brain  and  cord;  so  that  their  cells  may  have  an  opportunity  to  store 
up  again  a  renewed  quantity  of  nervous  energy. 

Later  on,  after  a  sufficiently  long  period  of  rest  has  been  enjoyed, 
a  plan  of  treatment  should  be  adopted  calculated  to  stimulate  and 
arouse  again  to  activity  the  dormant  cells  in  the  genital  centres;  but 
this  should  never  be  attempted  until  a  sufficient  period  of  complete 
repose  has  been  afforded  them. 

The  neurasthenia,  which  is  usually  present,  requires  the  first 
attention,  and  the  patient  should  be  directed  to  make  use  of  a  light, 
easily-assimilated  diet,  get  plenty  of  sleep,  and  take  gentle,  regular 
exercise  in  the  open  air. 


352  IMPOTENCE  AND  STERILITY. 

Eiding  on  horseback  and  the  bicycle  is  not  to  be  recommended, 
on  account  of  the  jarring  to  which  the  perineum  is  subjected  when 
these  are  indulged  in.  Sea-bathing  has  an  excellent  effect  as  a  general 
tonic. 

Especial  stress  should  be  laid  upon  the  necessity  for  avoiding  all 
sources  of  erotic  excitement,  such  as  lewd  books,  conversation,  and 
theatrical  displays;  companionship  of  women,  immoral  or  otherwise, 
and  all  attempts  at  sexual  intercourse  must  be  rigorously  interdicted. 

In  the  early  stages  of  treatment,  in  addition  to  blood-  and  tissue- 
building  tonics, — such  as  codliver-oil  and  iron, — the  spinal  sedatives 
— bromide  of  potash  and  lupulin — are  in  order  for  the  purpose  of 
giving  the  necessary  rest  to  the  exhausted  centres. 

After  this  treatment  has  been  continued  for  some  weeks  and  the 
patient's  neurasthenia  has  disappeared,  it  sometimes  happens  that  his 
sexual  functions  are  improved  as  well;  but  frequently  the  irritability 
of  the  genital  centre  is  still  so  exhausted  that  erections  either  do  not 
occur  at  all  or  are  not  sufficiently  vigorous,  and  ejaculation  is  prema- 
ture; so  that  a  special  stimulating  plan  of  treatment  has  to  be  adopted 
to  arouse  the  activity  of  the  cells  in  the  genital  centres. 

The  drugs  which  are  supposed  to  be  particularly  useful  as  stimu- 
lants to  the  nervous  centres  are  phosphorus  and  nux  vomica.  They 
may  be  combined  in  the  following  manner,  as  suggested  by  Gross: — ■ 

R  Quinise  sulphatis, 

Ferri   sulphatis. of  each  gr.  xl. 

Zinci  pliosphidi gr.  ij. 

Aeidi  arsenosi gv.  i«s, 

Stryclmise  sulphatis gr.  Va- 

M.  et  ft.  pil.  No.  xl. 

Sig. :    Two  pills  every  eight  hours. 

Damiana  and  cantharides  have  gained  some  reputation  among 
the  laity  as  aphrodisiacs,  but  damiana  has  little  or  no  effect,  and  can- 
tharides acts  as  an  irritant  upon  the  kidneys  and  bladder  whenever 
taken  in  doses  sufficiently  large  to  act  as  a  genital  excitant. 

It  was  hoped  that,  when  the  animal  extracts  were  first  introduced, 
they  might  prove  of  value,  but  extended  trials  of  them  have  only 
resulted  in  disappointment. 

Electricity  enjoys  a  high  reputation  in  the  treatment  of  atonic 
impotence.  The  constant  current  is  adapted  to  most  cases,  beginning 
with  the  positive  pole  applied  over  the  lumbar  region  and  the  negative 


ATONIC  IMPOTENCE.  353 

pole  used  to  stroke  the  penis,  testicles,  and  perineum.  The  strength 
of  the  current  may  be  gauged  by  the  sensitiveness  of  the  patient,  and 
it  should  not  be  used  strong  enough  to  cause  discomfort.  The  sittings 
at  first  should  be  for  two  or  three  minutes  every  forty-eight  hours, 
and  soon  increased  to  five  minutes  daily.  In  obstinate  cases,  if  erec- 
tions do  not  occur  from  these  applications,  the  positive  electrode  may 
be  introduced  into  the  rectum  and  a  more  powerful  effect  excited.  In 
cases  where  marked  anaesthesia  of  the  skin  of  the  genitals  exists,  the 
faradic  current  may  be  used,  with  better  results  than  the  galvanic. 

Cold  douches  or  the  alternate  use  of  cold-  and  hot-  water  douches, 
applied  with  some  force  to  the  spine  daily,  are  of  some  assistance,  and 
in  the  same  way  irrigation  of  the  rectum  with  hot  water  through  a 
Kemp  tube  may  be  of  some  service  as  a  local  stimulant  to  the  prostatic 
urethra. 

Local  treatment  of  the  urethra  is,  of  course,  demanded  when 
atonic  impotence  is  complicated  by  chronic  inflammation  of  the  poste- 
rior urethra  (see  "Symptomatic  Impotence");  but,  in  cases  where  the 
posterior  urethra  is  healthy  and  the  difficulty  is  a  pure  neurosis,  the 
passage  of  sounds  and  use  of  instillations  generally  increase  the  neu- 
rasthenia, and  the  patient  is  made  worse. 

The  operation  of  ligation  of  the  dorsal  vein  of  the  penis  has  been 
practiced,  with  the  object  of  retarding  the  return-flow  of  blood,  and 
so  allowing  the  erectile  tissue  of  the  corpora  cavernosa  to  become  dis- 
tended and  filled  up  with  blood,  in  the  cases  where  a  partial  erection 
occurred,  but  where  the  penis  almost  immediately  became  flaccid  with- 
out any  discharge  of  semen.  A  few  cases  have  been  reported  where 
this  operation  proved  successful,  but  the  mental  effect  of  an  operation 
may  have  been  partly  responsible  for  the  good  result. 

After  the  condition  of  impotence  has  yielded  to  protracted  and 
careful  treatment,  and  the  patient  is  again  able  to  have  erections  and 
ejaculate  normally,  he  should  be  warned  against  indulging  too  freely 
in  sexual  intercourse,  for  any  excess  in  this  line  will  be  very  apt  to  be 
followed  by  a  recurrence  of  his  former  disability. 


354  IMPOTENCE  AND  STERILITY. 

SYMPTOMATIC  IMPOTENCE. 

This  is  by  far  the  most  frequent  type  of  impotence  met  with  in 
practice.  The  disability  is  never  primary,  as  in  the  other  forms,  but 
it  is  always  dependent  upon  and  secondary  to  certain  structural  patho- 
logical changes,  located  in  the  nervous  system  or  the  urethra  and  its 
adnexa,  and  the  inability  to  copulate  is  only  one  symptom  of  many 
which  go  to  make  up  the  clinical  picture. 

In  symptomatic  impotence  erections  may  be  completely  absent, 
although,  as  the  genital  centres  in  the  nervous  system  are  not  affected, 
sexual  desire  is  usually  present. 

In  many  cases  a  partial  erection  of  the  penis  takes  place,  and  the 
seminal  fluid  is  ejaculated  prematurely.  This  form  is  generally  spoken 
of  as 

VARIETY  A.     IRRITABLE  IMPOTENCE. 

This  term  is  derived  from  the  fact  that,  on  account  of  the  irri- 
table state  of  the  posterior  urethra,  the  ejaculation  of  semen  occurs 
prematurely  before  the  penis  has  penetrated  into  the  vagina,  and  the 
organ,  which  never  attained  to  a  complete  erection,  becomes  flaccid 
immediately  after  the  discharge.  Many  of  these  cases,  which  are  char- 
acterized at  first  by  premature  ejaculation,  grow  worse,  and  in  time 
the  power  of  erection  disappears  entirely. 

Irritahle  impotence  generally  depends  upon  the  presence  of 
chronic  posterior  urethritis,  and  the  inflammation  often  extends  from 
the  urethra  through  the  ejaculatory  ducts,  and  the  prostate  and  sem- 
inal vesicles  become  affected  also. 

Chronic  posterior  urethritis  originates  from  a  gonorrhoea  or  from 
sexual  excesses,  masturbation,  or  the  pernicious  habit  of  interrupted 
coitus,  or  "withdrawal." 

These  causes  are  liable  to  induce  a  condition  of  chronic  engorge- 
ment of  the  blood-vessels  in  the  posterior  urethra,  and,  in  course  of 
time,  hyperplasia  of  the  submucous  connective  tissue  occurs,  and  the 
newly-formed  scar-tissue,  pressing  upon  the  delicate  nervous  struct- 
ures of  the  verumontanum,  occasions  various  reflex  symptoms  in  the 
brain,  nervous,  and  muscular  systems.  The  process  is  often  further 
complicated  by  germ-infection,  often  the  bacillus  coli,  which  aggra- 
vates the  existing  conditions. 

Instead  of  a  chronic  posterior  urethritis  being  responsible  for  the 
reflex  disturbances,  an  organized  stricture  may  be  present  in  the  pend- 


*  SYMPTOMATIC  IMPOTENCE.  355 

ulous  urethra,  and,  if  the  stricture  be  located  in  the  deeper  portion 
of  the  canal,  it  interferes  so  much  with  the  circulation  of  blood,  in  the 
posterior  urethra,  that  a  chronic  congestion  results,  which  disappears 
promptly  when  the  stricture  is  treated. 


TREATMENT. 

To  treat  the  symptom  of  irritable  impotence  successfully,  the 
condition  in  the  posterior  urethra  requires  attention.  (See  "Chronic 
Posterior  Urethritis,"  "Prostatitis,"  and  "Seminal  Vesiculitis.")  The 
discharge  of  pus,  if  present,  should  be  controlled  by  irrigations,  and 
later,  when  shreds  alone  are  found  floating  in  clear  urine,  instillations 
of  nitrate  of  silver  in  the  posterior  urethra  are  called  for. 

The  submucous  infiltration  can  be  favorably  influenced  by  the 
passage  of  large-sized  sounds.  An  instrument  of  particular  efficacy 
in  reducing  the  irritability  of  the  posterior  urethra  is  the  psychrophor, 
which  combines  the  benefits  of  pressure  with  the  effects  of  cold  in 
blunting  the  hypersensitiveness  of  the  nervous  system. 

If  the  prostate  or  vesicles  are  diseased,  massage  and  expression  of 
their  contents,  by  means  of  the  finger  in  the  rectum,  are  required  to 
bring  about  a  resolution  of  those  afi^ected  organs,  and,  if  a  stricture  is 
present,  it  must  receive  appropriate  treatment,  either  by  dilatation  or 
cutting. 

The  prognosis  of  irritable  impotence  is  good  in  so  far  as  we  can 
succeed  in  removing  the  cause  upon  which  the  impotence  depends. 

VARIETY  B.     PARALYTIC  IMPOTENCE. 

In  paralytic  impotence  erections  do  not  take  place  at  any  time, 
although  half-erections  sometimes  occur.  Ejaculation  does  not  occur 
at  all,  or  else  takes  place  without  causing  any  sensation,  and  the  semen 
is  not  ejected  in  jets,  but  gradually  oozes  from  the  meatus. 

On  examination  the  genitals  are  found  withered  and  flaccid,  and 
the  skin  of  the  penis  is  but  slightly  sensitive,  often  quite  anjesthetic. 
The  sensitiveness  of  the  urethra  is  diminished,  and  a  sound  may  be 
passed  with  ease  and  without  pain. 

Paralytic  impotence,  as  its  name  implies,  is  dependent  upon  or- 
ganic cerebral  or  spinal  disease,  which  causes  paral3'-sis  in  other  parts 
of  the  body.  Blows  upon  the  back  of  the  head  are  especially  liable 
to  be  followed  by  complete  impotence. 

In  locomotor  ataxia  in  the  early  stages,  there  may  be  a  condition 


356  IMPOTENCE  AND  STERILITY. 

of  priapism;  but,  as  the  case  progresses,  the  sexual  powers  decline, 
until  finally  the  patient  may  be  completely  impotent.  Myelitis  in 
mild  forms  does  not  affect  the  sexual  powers,  but  in  severe  forms  a 
state  of  impotence  is  induced. 

The  prognosis  in  paralytic  impotence  is,  of  course,  bad,  and  treat- 
ment, either  local  or  general,  is  of  little  or  no  use. 


VARIETY  C.     IMPOTENCE  RESULTING  FROM  DRUGS. 

Sexual  power  is  sometimes  diminished  or  entirely  destroyed  from 
the  excessive  use  of  certain  drugs.  Individuals  who  are  addicted  to 
the  habitual  and  excessive  use  of  opium,  chloral,  bromide  of  potash, 
and  hashish  are  very  apt,  in  time,  to  lose  sexual  inclination  and  power 
to  copulate.  Workmen  who  are  exposed  to  the  exhalations  of  certain 
chemicals — such  as  arsenic,  antimony,  and  lead — are  affected  in  the 
same  way. 

The  influence  of  an  excessive  quantity  of  alcohol  in  reducing 
sexual  power  is  a  matter  of  common  knowledge,  but  we  are  not  so 
certain  as  to  the  effects  of  tobacco,  although  some  authorities  claim 
that  tobacco  has  an  effect  in  lessening  both  sexual  inclination  and 
capacity. 

An  excess  of  sugar  in  the  blood,  which  occurs  in  diabetes,  also 
causes  impotence,  although  the  individual's  health  and  strength  are 
apparently  not  deteriorated. 

The  treatment  of  impotence  resulting  from  the  use  of  drugs  con- 
sists, of  course,  in  removing  the  cause,  and,  when  this  can  be  done,  the 
prognosis  is,  in  general,  favorable. 


STERILITY. 

Until  recent  years  a  condition  of  sterility  was  always  thought  to 
be  due  to  some  pathological  condition  on  the  part  of  the  woman  which 
prevented  conception.  It  is  now  recognized  that  in  a  small  number  of 
cases,  although  the  man  is  capable  of  performing  the  sexual  act,  still 
his  semen  is  destitute  of  the  fecundating  element,  and  he  is  sterile. 

As  an  example  of  this  state  may  be  cited  the  case  of  men  who 
have  been  castrated.  After  this  operation  the  subjects  do  not  become 
impotent  at  once,  but,  for  a  year  or  two  after  the  testicles  have  been 


STERILITY.  357 

removed,  are  able  to  practice  copulation  and  ejaculate  a  material 
composed  of  urethral  mucus  and  secretions  from  Cowper's  and  the 
prostate  glands,  but  devoid  of  spermatozoa,  and  hence  incapable  of 
impregnating  the  female. 

The  composition  of  normal  semen,  after  ejaculation,  is  found  to 
consist  of  spermatozoa  formed  in  the  testicles  and  the  secretions  of 
the  seminal  vesicles,  prostate,  Cowper's  glands,  and  the  glands  of  the 
urethral  mucous  membrane,  viz.:  Morgagni's  crypts  and  Littre's 
glands. 

The  usual  quantity  of  semen  ejaculated  at  one  discharge  is  from 
5ii-iv,  but,  if  coitus  is  repeated  frequently,  the  quantity  becomes 
smaller  each  time,  until  finally  only  a  few  drops  are  produced  with 
difficulty. 

The  essential  life-giving  element  in  semen  is,  of  course,  the 
spermatozoa,  and  the  function  of  the  other  ingredients  is  probably  to 
coat  the  urethral  mucous  membrane  and  dilute  the  semen. 

On  microscopic  examination  the  spermatozoa  present  a  most 
striking  picture,  showing  iiumerous,  small,  tadpole-shaped  bodies  mov- 
ing actively  in  the  field.  They  continue  to  show  movements  until  at 
least  twelve  hours  after  evacuation,  and  will  present  signs  of  activity 
for  forty-eight  hours  if  sheltered  from  light  and  cold. 

The  semen  also  contains  spermatic  cells,  which  are  supposed  to  be 
breeding-places  for  the  spermatozoa,  one  of'  which,  according  to 
Kolliker,  develops  out  of  each  nucleus  of  a  cell.  Bbttcher's  crystals  are 
discovered  on  adding  a  few  drops  of  1-per-cent.  solution  of  phosphate 
of  ammonia,  and  appear  as  variegated  groups  of  dagger-shaped  crys- 
tals. It  is  supposed  that  the  organic  base  of  the  crystals  exists  in  the 
secretion  of  the  prostatic  follicles,  and  gives  the  semen  its  character- 
istic odor. 

Finger  classifies  the  pathological  changes  in  the  semen  which 
cause  sterility  as  follows:— 

I.  Azoospermia,  or  absence  of  spermatozoa. 

II.  Oligozoospermia,  or  a  marked  diminution  in  the  number  of 
spermatozoa. 

III.  Xecrospermia:  The  spermatozoa  are  dead  and  without 
motion. 

IV.  Aspermia,  entire  absence  of  semen:  1.  Absolute.  3.  Tem- 
porary. 


358  lilPOTENCE  AND  STERILITY. 


I.  AZOOSPERMIA. 


In  this  condition  there  is  an  entire  absence  of  spermatozoa.  The 
physical  character  of  the  semen  is  not  distinguishable  from  normal; 
the  odor,  consistence,  and  color  are  unchanged;  and  the  absence  of 
spermatozoa  can  only  be  detected  by  the  microscope. 

Azoospermia  is,  of  course,  the  normal  condition  before  puberty, 
but  it  is  rarely  found  in  old  men,  who  usually  are  able  to  form  a  few 
spermatozoa. 

The  pathological  causes  which  bring  about  this  condition  may  be 
grouped  as  follows: — 

(a)  Frequent  seminal  emissions,  either  from  excessive  masturba- 
tion or  too  frequent  coitus,  cause,  first,  a  diminution  in  number,  and, 
if  persisted  in,  a  complete  disappearance  of  spermatozoa,  which  reap- 
pear in  the  semen  again  after  a  few  days'  rest. 

(b)  Disturbance  of  the  Sepreting  Function  of  the  Testicle. — This 
generally  occurs  in  the  acute  fevers,  and  the  debility  following  con- 
valescence, and,  as  a  result,  the  spermatozoa  disappear  temporarily 
from  the  semen.  In  chronic  diseases  the  same  often  occurs,  and 
azoospermia  often  exists  in  tuberculosis  and  in  syphilis,  even  when  the 
testicles  are  not  affected. 

(c)  Disease  of  the  testicle,  caused  by  syphilis,  tuberculosis,  or 
malignant  disease,  if  it  is  bilateral  and  destroys  completely  the  paren- 
ch3'ma  of  the  organ,  interferes  with  the  formation  of  spermatozoa  and 
leads  to  sterility.  It  is  necessary,  however,  that  it  should  be  a  com- 
plete destruction,  for,  if  a  small  part  of  the  secreting  portion  is  left, 
spermatozoa  may  still  be  formed. 

(d)  Absence  of  both  testicles — either  from  removal  by  castra- 
tion, atrophy  consecutive  to  orchitis,  congenital  absence,  or  atrophy 
following  ectopia  testis — will,  of  course,  induce  permanent  and  irre- 
mediable sterility. 

(e)  Bilateral  obstruction  of  the  vas  deferens  is  the  commonest 
cause  of  azoospermia,  and  results  from  epididymitis,  which  in  90  per 
cent,  of  the  cases  is  due  to  gonorrhoea.  Tuberculosis  and  syphilis  are 
responsible  for  the  remaining  10  per  cent.  The  obliteration  of  the 
vas  deferens  is  caused  by  the  pressure,  upon  the  seminiferous  tubes, 
of  a  mass  of  inflammatory  scar-tissue  in  the  tail  of  the  epididymis, 
which  contracts,  and  squeezes  the  tubes  together.  Finger  cites  242 
cases  of  double  epididymitis,  out  of  which  207  suffered  from  azoo- 
spermia. 


NECROSPERMIA. 


359 


The  treatment  of  azoospermia  seldom  meets  with  much  success, 
except  in  cases  of  syphilitic  epididymitis.  Here  an  energetic  course 
of  antisyphilitic  medication  will  often  cause  absorption  of  the  infiltra- 
tion, and  the  testicle  resumes  its  function. 

In  gonorrhoeal  epididymitis  the  infiltration  is  hard  and  dense, 
and  after  it  has  existed  some  little  time  it  is  impossible  to  bring  about 
its  absorption.  It  is  important,  for  this  reason,  to  treat  every  case  of 
gonorrhoeal  epididymitis  carefully,  in  order  to  avoid  the  danger  of 
sterility  (see  "Epididymitis"). 


II.  OLIGOZOOSPERMIA. 

This  condition  consists  in  a  marked  diminution  of  the  number  of 
the  spermatozoa,  and  may,  in  general,  be  regarded  as  a  temporary  con- 
dition, which,  depending  upon  its  cause,  either  returns  to  the  normal 
state  or  goes  over  into  complete  absence  of  spermatozoa  (azoospermia). 

Oligozoospermia  occurs  normally  in  old  age  and  at  the  beginning 
of  puberty,  and  it  also  occurs  in  general  debility  from  any  disease  and 
also  after  repeated  acts  of  sexual  intercourse.  The  most  usual  causes 
for  it  are  gonorrhoeal  epididymitis  or  new  growths — either  syphilis, 
tuberculosis,  or  cancer — which  involve  the  epidi'dymis. 

As  long  as  the  vasa  deferentia  are  not  completely  closed  by  the 
inflammation,  a  few  spermatozoa  may  make  their  way  through  the 
canal.  If  the  spermatozoa  are  diminished  in  number,  and  at  the  same 
time  motionless,  sterility  is  assured;  but,  if  the  spermatozoa  retain 
their  movement,  there  is  always  procreative  power  left,  but  in  a 
lessened  degree. 


III.  NECROSPERMIA. 

In  this  condition  the  male  is  able  to  copulate  and  to  ejaculate 
semen,  but  on  microscopic  examination  the  spermatozoa  are  found 
to  be  dead  and  without  motion.  In  order  to  make  a  valid  test,  it  is 
necessary  to  examine  the  semen  not  later  than  one  to  two  hours  after 
ejaculation,  and  the  specimens  can  only  be  secured  by  directing  the 
man  to  have  coitus  while  wearing  a  condom. 


360  IMPOTENCE  AND  STERILITY. 

Xecrospermia  is  brought  about  by  a  variety  of  causes  which  di- 
minish the  secreting  capacity  of  the  testicle.  Excesses  in  venery  or 
unduly  frequent  seminal  emissions  operate  in  this  way.  At  first  the 
semen  is  normal,  but  in  time  it  becomes  thinner,  the  numbers  and 
motility  of  the  spermatozoa  diminish,  and  they  become  small,  de- 
formed, and  unripe. 

The  same  effect  is  produced  upon  the  spermatozoa  by  a  disturb- 
ance in  the  nutrition  of  the  testicle  from  alcoholism,  morphinism, 
general  tuberculosis,  or  diabetes.  Various  local  processes — such  as 
syphilis,  carcinoma,  and  beginning  atrophy — exert  their  effect  upon 
the  parenchyma  of  the  gland,  and  the  formation  of  spermatozoa  is 
affected  in  consequence. 

A  more  frequent  cause  of  the  death  of  the  spermatozoa  is  some 
pathological  alteration  of  the  component  parts  of  the  semen.  Inflam- 
mation of  the  seminal  vesicles,  either  acute  or  chronic,  causes  percep- 
tible alteration  in  the  semen.  It  is  usually  purulent  and  sometimes 
bloody,  deriving  its  foreign  constituents  from  the  inflamed  cavities  of 
the  vesicles,  and  the  spermatozoa  are  found  to  be  dead. 

The  spermatozoa  are  also  motionless  in  cases  of  chronic  follicular 
prostatitis,  for,  as  Flirbringer  has  demonstrated,  the  spermatozoa,  so 
long  as  they  are  retained  in  the  seminal  vesicles,  are  motionless,  and  it 
requires  the  contact  of  the  prostatic  secretion  to  arouse  their  normal 
motility.  When  the  prostatic  follicles  are  diseased,  their  secretion  is 
checked,  and  the  spermatozoa  are  deprived  of  the  stimulant  necessary 
to  excite  their  activity. 

As  already  indicated,  the  treatment  of  necrospermia  will  depend 
upon  the  cause  which  occasions  it,  and  the  prognosis  is  good  or  other- 
wise as  we  are  able  to  remove  its  orio^in. 


IV.  ASPERMIA. 

Aspermia  may  be  defined  as  a  condition  in  which  the  male  is  able 
to  perform  coitus  properly,  but  no  semen  is  ejaculated  into  the  vagina 
of  the  female,  either  because  none  is  secreted  or  because  some  obstruc- 
tion in  the  urethra  prevents  its  passing  from  the  meatus. 

Aspermia  may  be  either  absolute  or  temporary,  congenital  or  ac- 
quired. 

Congenital  aspermia  is  a  very  rare  condition,  but  a  few  cases  have 


ASPERMIA.  361 

been  reported.  Ultzmann  assumed  it  to  be  due  to  a  non-excitability 
of  tlie  reflex  centre  of  ejaculation.  Jacobson  suggests  that,  while  the 
testicles  are  present  and  capable  of  forming  spermatozoa,  they  cannot 
make  their  way  into  the  urethra  on  account  of  an  occlusion  of  the 
ejaculatory  ducts  or  an  absence,  from  anomaly  of  development,  of  a 
portion  of  the  vas  deferens. 

Acquired  aspermia  is  not  uncommon  and  is  often  the  result  of 
suppurative  affections  of  the  prostate  brought  about  by  gonorrhoea  or 
tuberculosis.  Through  the  destruction  of  the  gland  and  the  subse- 
quent formation  of  scar-tissue,  the  ejaculatory  ducts  are  closed  by  the 
contraction  of  the  cicatrix.  If  one  duct  is  left  open,  the  semen  is 
diminished  in  quantity,  but  not  noticeably  so;  but,  if  both  ducts  are 
closed,  aspermia  follows. 

The  ejaculatory  ducts  are  also  occasionally  destroyed,  during  a 
lateral  lithotomy,  either  by  being  cut  in  incising  the  posterior  urethra 
or  by  suffering  laceration  in  dragging  a  large  stone  out  of  the  bladder 
and  through  the  wound. 

The  ejaculatory  ducts  sometimes  become  plugged  by  the  forma- 
tion of  concretions  composed  of  spermatozoa,  mucus,  epithelial  cells, 
and  lime-salts. 

An  insensitive  condition  of  the  glans  penis  may  be  responsible  for 
the  failure  of  ejaculation,  and  cases  have  been  reported  where  an  in- 
jury to  the  spine  caused  a  complete  anaesthesia  of  the  skin  of  the 
genitals.  In  another  case  on  record  the  prepuce  and  dorsum  of  the 
penis  had  been  destroyed  by  ulceration  and  converted  into  a  large 
indurated  scar,  which  was  entirely  insensitive. 

One  of  the  most  frequent  causes  of  aspermia  is  stricture  of  the 
urethra.  On  account  of  the  swollen  and  turgid  condition  of  the  mu- 
cous membrane  of  the  urethra  during  coitus>  the  orifice  of  a  tight 
stricture  is  closed,  and  the  seminal  fluid  is  unable  to  escape  past  it, 
but  is  retained  in  the  urethra  behind  the  stricture.  After  the  con- 
gestion subsides  the  verumontanum  no  longer  closes  the  vesical  out- 
let, and  the  semen  regurgitates  into  the  bladder,  and  is  subsequently 
discharged  with  the  urine. 

Temporary  aspermia  is  a  rare  condition  which  occurs  in  persons 
of  a  nervous  temperament  who  become  neurasthenic  from  excesses  in 
venery,  masturbation,  or  gonorrhoea.  Such  individuals  are  usually  im- 
potent (psychical  impotence),  but  occasionally  such  patients  are  found 
who  can  copulate,  but  cannot  ejaculate  any  semen  at  the  time,  al- 
though the  seminal  fluid  may  escape  a  few  hours  later  during  sleep, 

24 


363 


IMPOTENCE  AND  STERILITY. 


as  an  emission.     This  form  of  aspermia  begins  suddenly,  lasts  a  few 
weeks  or  months,  and  then  vanishes  as  suddenly  as  it  came. 

The  treatment  of  aspermia  in  its  various  forms  depends  upon  the 
etiology,  but  the  variety  depending  upon  stricture  offers  a  good  prog- 
nosis when  the  urethra  is  restored  to  its  normal  calibre. 


LIST  OF  GENITO-URINAKY  INSTRUMENTS.  363 


LIST  OF  GENITO-URINARY  INSTRUMENTS  REQUIRED 
FOR  OFFICE  USE. 

Valentine's  irrigator. 

Ultzmann's  syringe. 

Large  hard-rubber  or  glass  syringe.     Capacity,  4  to  6  ounces. 

Oberlaender  or  Kollmann's  dilator,  antero-posteror. 

Otis  urethrometer. 

Eighteen  steel  sounds.  Van  Buren  curve.  Numbers  16  to  34 
French,  inclusive,  but  omitting  every  other  number. 

Benique  sounds,  16  to  34  inclusive,  omitting  every  other  number. 

Tunneled  sounds,  numbers  12,  14,  16,  18,  and  20  French. 

Psychrophor  with  Benique  curve;  attached  to  four-quart  douche- 
bag. 

Bougies  a  boule,  metal;  numbers  16  to  32  inclusive,  omitting 
every  other  number. 

Guyon's  flexible  gum-elastic  bougies  a  boule,  16  to  30  French, 
omitting  every  other  number. 

One  dozen  whale-bone  guides. 

Thompson's  searcher  for  stone. 

Mtze's  observation  cystoscope. 

Six  Klotz  endoscopes  (Eissner  &  Co.,  New-  York):  3  four  inches 
long.  Calibre,  respectively,  26,  28,  and  30  French.  One  five  and  one- 
half  inches  long.  ISTumber  26  French.  Two  six  inches  long.  Num- 
bers 28  and  30  French. 

Head-mirror. 

Oil-lamp  (Belgian  or  other  circular  wick,  with  central  draft). 

Long  urethral  forceps. 

Hypodermic  syringe  for  injecting  mercurial  salts  (Eissner  &  Co., 
New  York). 

Catheters:  Soft  rubber.  Silver,  with  prostatic  curve.  Mercier 
coude  and  bicoude  (prostatic).  One  Gouley  tunneled  silver  catheter, 
English,  with  st5det. 

Flexible  bougies  from  number  18  down  to  smallest. 


INDEX. 


Alopecia,  298. 

Anatomy  of  the  urethra,  16. 

Asperniia,  360. 

acquired,  361. 

congenital,  360. 

temporary,  361. 
Azoospermia,  358. 

causes  of,  358. 

Bacteriuria,  154. 

course  of,   155. 

diagnosis  and  treatment  of,  155. 

prognosis   of,   155. 

symptoms  of,  155. 
Balano-posthitis,  5. 

diagnosis  of,  6. 

symptoms  and  course  of,  5. 

treatment  of,  6. 
Bladder,      avenues      through      which 
micro-organisms     reach      the, 
137. 

benign  tumors  of  the,  156. 

malignant  tumors  of  the,  156. 

solutions  for  washing  the,  149. 

tumors  of  the,  diagnosis  of,  157. 
prognosis  of,   158. 
symptoms  of,  157. 
treatment   of,   158. 
Bubo,  280. 

course  of,  281. 

differential  diagnosis  of,  281. 

etiology  of,  280. 

operative  treatment  of,  282. 

treatment  of,  281. 

Calculi,  oxalic,   159. 
phosphatic,  159. 
uratie,  159. 
Calcvilus    in   children,   operations   for, 
180. 
renal,  229. 

colic  as  a  symptom  of,  230. 
diagnosis  of,  232. 


Calculus,  renal,  disturbances  of  urinary 
function  as  a  symptom  of,  231. 

etiology  of,   229. 

gastro-intestinal  disturbances  ac- 
companying, 231. 

hsematuria  as  a  symptom  of,  231. 

pain  as  a  symptom  of,  231. 

passage  of  fragments  in,  231. 

prognosis   of,  232. 

pyuria  as  a  symptom  of,  231. 

symptoms  of,  230. 

treatment  of,  233. 
vesical,  159. 

blood  as  a  symptom  of,  166. 

causes  of  phosphatic,   165. 

diagnosis  of,  166. 

etiology  of,  160. 

increased    frequency    of    urination 
as  a  symptom  of,   106. 

litholapaxy  in  the  treatment  of, 

i7o: 

number  of,  159. 

operative  treatment   of,   170. 

pain  as  a  sj-mptom  of,  165. 

perineal   lithotomy   in  the   treat- 
ment of,  173. 
lithotrity  in  the  treatment  of, 
174. 

predisposing  causes  of  uratie  and 
oxalic,  160. 

preventive  treatment  of,  168. 

sudden  stoppage  of  the  urine  as 
a  symptom  of,   166. 

symptoms  of,   165. 

the   cystoscope    in    the    diagnosis 
of,  168. 

the  litholapaxy  pump  in  the  di- 
agnosis of,  168. 
Cancer  of  the  penis,  12. 
amputation  of  the  entire  penis  for, 
14. 

free  portion  of  the  penis  for,   14. 
(3G5) 


366 


INDEX. 


Cancer,  course  of,  13. 

diagnosis  of,  13. 

etiology  of,  12. 

operations  for,  14. 

prognosis  of,  13. 

treatment  of,  14. 
Caput  gallinaginis,  21. 
Catheter,  Mercier,  200. 

the  silver  prostatic,  200. 
Chancre,  28t. 

course  of,  2S4. 

definition  of,  284. 

diagnosis  of  the,  288. 

differential  diagnosis  of,  289. 

duration  of  the,  288. 

heals  without  leaving  a  scar,  288. 

length  of  time  after,  at  which  in- 
fection of  the  foetus  is  liable 
to  occur,  322. 

of  the  urethra,  288. 

pathology  of,  286. 

prognosis  of,  290. 

transmission  of  contagion  of,  285. 

treatment   of,  290. 

vaccination,  285. 

varieties  of,  287. 
Chancroid,  271. 

characteristics  of,  272. 

complicated  by  paraphimosis,  279. 
by  phagcdfena,  279. 

complications  of,  278. 

course  of,  272. 

diagnosis   of,  276. 

duration  of,  275. 

etiology  of,  271. 

frequency  of,  272. 

microscopic  examination  of,  275. 

modes  of  contagion  of,  272. 

subpreputial,  complicated  by  phi- 
mosis, 278. 

treatment  of,  276. 
Chordee,  26. 
Circumcision,  3. 

by  dorsal  incision  and  trimming  off 
the  flaps,  3. 

with  a  clamp,  3. 
Compressor  urethrae,  16. 
Condyloma,  297. 
Cystitis,   134. 


Cystitis,  acute,  balsams  in  the  treatment 
of,  145. 

diluents  in  the  treatment  of,  144. 

general   treatment  of,  144. 

hot   sitz-baths   in    the   treatment 
of,    144. 

instillations   of   nitrate   of   silver 
in,   146. 

local  treatment  of,  146. 

opium  in  the  treatment  of,  145. 

purgatives   in   the   treatment   of, 
144. 

the  diet  in,  144. 

urinary  antiseptics  in  the  treat- 
ment of,  145. 
chronic,  general  treatment  of,  146. 

local  treatment  of,   147. 

perineal  drainage  in,  147. 

solutions    for   washing   the    blad- 
der  in,    149. 

suprapubic  drairage  in,  148. 
classification  of,  138. 
constitutional  symptoms  in,   141. 
diagnosis  of,  142. 
etiology  of,  134. 
frequent  urination  in,  140. 
gonorrhoeal,  150. 
hsematuria  in,   141. 
membranous,  139. 
micro-organisms  found  in,   135. 
painful  urination  in,  140. 
pathological  changes  in,  138. 
preventive  treatment  of,   143. 
prognosis   of,   143. 
pyuria  in,   141. 
simple,  138. 
specific,   150. 
sj'Uiptoms  of,  140. 
tuberculous,  150. 

diagnosis  of,  151. 

involvement    of    the    bladder    in, 
152. 

microscopic    examination    of    the 
pus  in  the  diagnosis  of,  152. 

modes  of  infection  in,  150. 

pathological  changes  in,  151. 

prognosis   of,    152. 

symptoms  and  course  of,  151. 

the   cystoscope   in   the   diagnosis 
of,   151. 


INDEX. 


367 


Cystitis,  tuberculous,  treatment  of,  152. 
Cystoscope,  the,  in  the  diagnosis  of 

tuberculous  cystitis,  151. 
in  the  diagnosis  of  tumors  of  the 

bladder,  157. 
Cystotomy  in  the  diagnosis  of  tumors 

of  the  bladder,  157. 

Dilator,   Oberlaender,  59. 

Ejaculation,  mechanism  of,  346. 
Epididymis,   channels   through   which 

tubercle  bacilli  are  conveyed 

to,  247. 
Erection,  mechanism  of,  346. 

Fossa  navicularis,  21. 

Genito-urinary    instruments    required 

for  office  use,  363. 
Gonococcus,    Gram's    method    of    de- 
tecting, 29. 
morphology  of  the,  28. 
Van  den  Bergh's  method  of  detect- 
ing, 28. 
GonorrhcEa,  23. 

acute,  balanitis  as   a   complication 
of,  75. 
chordee  as  a  complication  of,  76. 
complications  of,  75. 
Cowperitis  as  a  complication  of, 

76. 
epididymitis    as    a    complication 

of,  79. 
folliculitis   as  a   complication   of, 

75. 
inguinal  adenitis  as  a   complica- 
tion of,  76. 
paraphimosis    as    a    complication 

of,  75. 
phimosis  as  a  complication  of,  75. 
anterior,     advantages     of     Janet's 
method  in,  37. 
astringent  injections  in,  33. 
disadvantages  of  Janet's  method 

in,  37. 
irrigations  with  permanganate  of 

potash  in,  35. 
Janet's  method  in,  35. 


Gonorrhoea,  anterior,  method  of   using 
the  salts  of  silver  in,  39. 
technique   of  Janet's   method   in, 

37. 
the  abortive  treatment  of,  35. 
the  salts  of  silver  in,  38. 
treatment  of  the  stage  of  decline 
of,  32. 
causes  which  retard  recovery  from, 

30. 
course  of,  26. 

duration  of  an  attack  of,  29. 
endoscopic  examination  of,  26. 
examination  of  urine  in,  27. 
healing  of  the  lesions  of,  25. 
microscopic  examination  of  pus  in, 

27. 
pathology  of,  23. 
prodromal  stage  of,  26. 
relapses  of,  25. 
treatment  of,  30. 
Gonorrhoeal  rheumatism,  81. 

treatment  of,  82. 
Gumma,  310. 

of  the  skin  and  subcutaneous  tis- 
sues, 310. 

Hsematocele,  264. 
etiology  of,  264. 
of  the  spermatic  cord,  265. 
symptoms  and  course  of,  264. 
treatment  of,  204. 
Herpes  progenitalis,  8. 
diagnosis   of,  8. 
etiology  of,  8. 
treatment  of,  8. 
Hydrocele,  255. 
acute,  255. 

etiology  of,  255. 

pathology  of,  255. 

purulent,  256. 

symptoms   of,   256. 

treatment  of,  256. 
chronic,  256. 

incision  of  the  sac  for,  262. 

pathology  of,  259. 

puncture  of,  261. 

radical  treatment  of,  by  injection, 
261. 

symptoms  and  diagnosis  of,  200. 


3G8 


INDEX. 


Hydrocele,  chronic,  treatment  of,  260. 

congenital,  255. 

of  the  spermatic  cord,  263. 
treatment  of,  263. 
Hydronephrosis,  239. 

diagnosis   of,  241. 

etiology  of,  240. 

intermittent,  240. 

prognosis  of,  241. 

symptoms  ol,  241. 

treatment  of,  242. 

Impotence,  345. 
atonic,  350. 

diagnosis  and  treatment  of,  351. 
classification  of  forms  of,  346. 
irritable,  354. 

treatment,  355. 
organic,  347. 

treatment  of,  347. 
paralytic,  355. 
psychical,  348. 

treatment  of,  349. 
relative,  349. 

resulting  from   drugs,  356. 
symptomatic,  354. 

Kidney,  movable,  226. 
diagnosis  of,  228. 
etiology  of,  226. 
prognosis  of,  228. 
symptoms  of,  227. 
treatment  of,  228. 
surgical,  234. 
true  floating,  226. 
Kollmann's  posterior  dilator,  65. 

Litholapaxy,  mortality  of,  173. 
Lithotomy,    perineal,    median    opera- 
tion of,  174. 
mortality  of,  176. 
suprapuV)ic,    1 76. 
mortality   of,   179. 
Littre,  glands  of,  21. 

Mixed  sore,  275. 

Morgagni,  follicles  of,  21. 

Mucous  patch,  297. 

Muscle,  cut-off,  of  the  urethra,  16. 

Necrospermia,  350. 
Nephrectomy,  233. 
Nephrolithotomy,  233. 


Oberlaender  dilator,  59. 
Oligozoospermia,  359. 
Osteophyte,  340. 

Papillomata,  11. 
diagnosis  of,  11. 
treatment  of,  11. 
Penis,  cancer  of  the,  12. 
Phagedsena,   serpiginous,   280. 

sloughing,  280. 
Phimosis,  1. 
acquired,  1. 
congenital,  1. 
direct  results  of,  1. 
remote  results  of,  2. 
temporary,   1. 
treatment  of,  3. 
Profeta's  law  of  immunity,  321. 
Prostate,  diminution   in   size   of,   after 
castration,  210. 
hypertrophied,    Alexander's    opera- 
tion   of    perineal    prostatec- 
tomy for,  206. 
Bottini's  operation  for,  203. 
castration  for,  210. 
choice  of  operations  in,  217. 
clinical  results  of  castration  for, 

211. 
Fuller's   operation   of   suprapubic 

prostatectomy  for,  208. 
mortality  of  castration  for.  213. 
operative  treatment  of,  202. 
palliative  operations  for,  216. 
perineal  opening  for,  216. 
prostatectomy  for,  205. 
prostatotomy  for,  205. 
puncture  with  a  trocar  for,  217. 
remote    results    of    castration   for, 

214. 
results    of    suprapubic    and    peri- 
neal  prostatectomy   for,  209. 
suprapubic  cystotomy  for,  216. 
suprapubic     prostatectomy      for, 

207. 
vasectomy  for,  215. 
senile  hypertrophy  of  the,  181. 
atrophy    and    distension    of    the 

bladder  in,  192. 
changes    in    kidneys    and   ureters 
in,   193. 


INDEX. 


369 


Prostate,  senile,  changes  in  the  ureter 
in,  189. 

changes  in  the  wall  of  the  blad- 
der in,  191. 

commencement     of     catheter-life 
in,  199. 

continuous      catheterization      in, 
200. 

cystoscopic    examination    in    the 
diagnosis  of,  194. 

diagnosis  of,  194. 

form  of  obstruction  in,  182. 

general  treatment  of,  195. 

hypertrophy  with  contraction  of 
the  bladder  in,   192. 

incontinence  of  urine  in,  192. 

pathology  of,   181. 

rectal  examination  in  the  diagno- 
sis of,  194. 

residual   urine   in,   191. 

retention  of  urine  in,  193,  199. 

saccular   dilatation    of    the   blad- 
der in,  192. 

suprapubic     aspiration      of     the 
bladder   in,   200. 

symptoms  ot,   190. 

the  quantity  of  residual  urine  in 
the  diagnosis  of,  194. 
tuberculosis  of  the,  221. 

diagnosis  of,  223. 

pathology  of,  222. 

prognosis   of,   224. 

symptoms  and  course  of,  222. 

treatment  of,  224. 
Prostatitis,  acute,  84. 

follicular,  84. 
chronic,  87. 

diagnosis  oi,  88. 

pathological   anatomy    of,   87. 

prognosis  of,  90. 

symptoms  of,  87. 

treatment  of,  88. 
parenchymatous,  course  and  termi- 
nation of,  85. 

diagnosis  of,  86. 

symptoms  of,  85. 

treatment  of,  80. 
simple  acute,  84. 
Prostatorrhoea,  87. 

Psychrophor     in     the     treatment     of 
chronic   prostatitis,   89. 


Psychrophor,  the,  65. 
Pyelitis,   234. 

diagnosis  of,  236. 

etiology  of,  235. 

prognosis  of,  237. 

symptoms   of,   235. 

treatment  of,  238. 
Pyelonephritis,  234. 

liheumatism,  gonorrhoeal,  81. 

Salivation,  treatment  of,  328. 
Sinus  pocularis,  21. 
Sound,  the  Benique,  65. 
in  the  treatment  of  chronic  prosta- 
titis, 89. 
the  cold  water,  65. 
Sterility,  356. 
Stone,  sounding  for,  166. 
Stricture,  annular,  lO-l. 
cicatricial,  104. 
complicated   with   a   false   passage, 

126. 
inodular,  104. 

intractable,  treatment  of,  by  resec- 
tion   of    a    portion    of    the 
uiethra,  127. 
linear,  104. 
of  the  meatus,  126. 
of  the  urethra,  102. 
organic,   102. 

abscess  of  the  kidney  in,  107. 
changes  in  bladder  and  kidney  in, 

106. 
changes  which  take  place  behind 

the,  105. 
continuous    dilatation    in    treat- 
ment of,  116. 
dangers  of  internal  urethrotomy 

in,  120. 
definition   of,   102. 
diagnosis  of,  108. 
distension  of  kidneys  in,   107. 

of  ureters  in,  107. 
distorted   stream   in,    107. 
dribbling  after  urination  in,   107. 
effects   upon,   of   passing  sounds, 

114. 
etiology  of,  103. 
external  urethrotomy  in,  121. 


370 


INDEX. 


Stricture,  organic,  false  passage  in,  110. 

flexible  bulbous  bougie  in  diag- 
nosis of,  108. 

frequent  urination  in,  107. 

gleety  discliarge  in,   107. 

Gouley's  tunneled  catheter  in, 
117. 

gradual  dilatation  in,  110. 

hj'dronephrosis  in,   107. 

hj'pertrophy  of  bladder-wall  in, 
lOG. 

immediate  operation  in,   117. 

interference  with  coitus  in,  108. 

internal  urethrotomy  in,  118. 

location  of,  104. 

metal  bulb  in  diagnosis  of,  109. 

numbers  of,  104. 

Oberlaender  dilator  in  treatment 
of,  115. 

of  very  small  calibre,  116. 

Otis's  urethrometer  in,   109. 

pain  in  the  urethra  in,  108. 

pathology   of,    103. 

pouching  of  urethra  in,  103. 

pyelitis   in,   107. 

relapses  of,  116. 

residual  urine  in,  107. 

retention  of  urine  in,  107. 

summary  of  indications  for  in- 
ternal urethrotomy  in,  120. 

symptoms  of,  107. 

treatment  of,   110. 

by  surgical  operation,  117. 

tunneled  sound  and  gradual  dila- 
tation in  the  treatment  of, 
116. 

ulceration  in,  105. 

varieties  of,   103. 

vesical  atony  in,  107. 

whalebone  filiform  guides  in  the 
diagnosis  of,  109. 

spasmodic,    102. 
causes    of,    102. 

tortuous,    104. 
Syphilide,  macular,   299. 
papular,  299. 
papulo-piistular,  299. 
papulo-squamous,  299. 
pigmentary.  299. 
pustular,  299. 


Syphilide,  rupial,  313. 

tubercular,  dry   or  atrophic,  313. 

ulcerative  form  of,  313. 
Syphilides,  298. 

absence  of  burning  and  itching  in, 

308. 
color  of,  308. 

distribution  of,  over  the  body,  300. 
Syphilis,  292. 

abortion   of,  after  infection,  291 
administration    of   mercury    by  the 

mouth  in,  330. 
and  irritation,  314. 
and  marriage,  323. 
and    the    eruptive    fevers,    analogy 

between,  292. 
cachexia  of,  336. 
carriers   of   the   poison   of,  292. 
course    of    virus    of,    through    the 

lymphatic  system,  296. 
diagnosis  of,  324. 

duration  of  secondary  stage  of,  308. 
fumigation   by  calomel   in,  329. 
glandular  enlargement  of,  295. 
hereditary,  late,  338. 
immunity  in,  319. 
incubation  of,  295. 
infection  of  foetus  in,  320. 
influence  of  the  child's,  as  exerted 

upon  the  mother,  321. 
inherited,  320,  338. 

afiections  of  the  nervous  system 
in,  340. 

affections  of  the  viscera  in,  339. 

condylomata   in,  339. 

course   of,   339. 

duration  of  treatment  of,  344. 

eruptions  upon  the  skin  in,  339. 

htBmorrhagic,  340. 

Hutchinson's   teeth   in,   340. 

interstitial   keratitis  in,  343. 

osteochondritis   in,  340. 

snuffles  in,   339. 

treatment  of,  343. 
inoculation  and  course  of,  293. 
intramuscular   injections   in,   330. 
inunction  of  mercury  in,  328 
iodide  of  potash  in,  332. 
local  treatment  of  lesions  of,  337. 
malignant,  314. 
mercury   in  the  treatment   of,   327. 


INDEX. 


371 


Syphilis,  mode  of  increase  of  the  virus 
of,  294. 
modes  of  administering  mercury  in, 

328. 
preparations    of    mercury   used   in, 

331. 
prodromal    symptoms,    or    prodro- 

mata,  296. 
Profeta's  law  of  immunity  in,  321. 
prognosis  of,  325. 
recognition    of   inherited    taint    of, 

340. 
secondary,  296. 

albuminuria      as      a      prodromal 

sj'niptoni  of,  297. 
alopecia  of,  298. 
classification     and     anatomy    of, 

299. 
condyloma  of,  297. 
course  of  the  eruption  of,  307. 
erythema  of  the  fauces  as  a  pro- 
dromal symptom  of,  297. 
fever   as    a    prodromal   symptom 

of,   296. 
jaundice   as    a    prodromal   symp- 
tom of,  297. 
mucous  patch  of,  297. 
nocturnal   pains  as  a   prodromal 

symptom  of,  296. 
skin  eruptions  of,  298. 
stages  of,  294. 
sublimate  baths  in,  330. 
tertiary,    anatomical     changes     in, 
309. 
characters  of  lesions  of  skin  and 

mucous  membrane  in,  309. 
characters   of  skin   eruptions   of, 

310. 
gummatous   arteritis   in,   309. 
pathology   of,   309. 
stage  of,  308. 
the   hot   springs   of   Arkansas   and 

Aachen   in,  333. 
the  virus  of,  292. 
therapeutics  of,  333. 
treatment  of,  327. 
mild  forms  of,  334. 
primary  stage  of,  333. 
severe  forms  of,  335. 
Zittmann's  decoction  in,  332. 
Syphilitic  eruptions,  relapsing,  300. 


Syphilitic  erythema,  299. 

mother,  termination  of  pregnancies 

in  a,  322. 
roseola,  299. 


Testicle,  ectopy  of  the,  243. 

complications  of,  244. 

diagnosis  of,  245. 

etiology  of,  244. 

results  of,  244. 

treatment  of,  245. 
galloping  consumption  of  the,  249. 
malignant  disease  of  the,  246. 

clinical  history  of,  246. 

prognosis  and  treatment  of,  247. 

varieties  and  description  of,  246. 
syphilis  of  the,  252. 

diagnosis  of,  253. 

prognosis  of,  253. 

symptoms  and  course  of,  253. 

treatment  of,  254. 
tuberculosis  of  the,  247. 

castration  for,  251. 

course  of,  248. 

erosion  or  curetting  for,  251. 

operative  treatment  of,  251. 

prognosis  of,  250. 

symptoms  and  diagnosis  of,  250. 

treatment  of,  251. 

Urethra,  anatomj'  of  the,  16. 
anterior,  16. 

normal  appearance   of,  69. 
aseptic  catarrh  of  the,  22. 
bulbous,  21. 

cut-off  muscle  of  the,  16. 
membranous,   16. 
mucous  membrane  of  the.  21. 
normal  appearance  of,  70. 
physiological  narrowing  of  the,  21, 
points  of  widening  of  the,  21. 
posterior,  21. 
prostatic,  21. 
Urethral  instruments,  care  of,  132. 
Urethritis,  acute,  22. 

predisposing  causes  of,  22. 
anterior,  30. 
chronic,   47. 
changes  in  the  mucosa  in,  49. 
diagnosis  of,  52. 


373 


INDEX. 


Urethritis,  anterior,  chronic,  final  heal- 
ing of  the  lesions  in,  50. 
glandular  changes   in,  48. 
instillations  in,  55. 
isolated  foci  of,  55. 
method    of    using    Otis's    ure- 

thrometer  in,  54. 
passage  of  steel  sound  in,  58. 
pathology  of,  47. 
sj'mptoras  ct,  51. 
treatment  of,  54. 
treatment  of  the  deep  form  of, 

58. 
treatment   with   the  endoscope 

in,  58. 
Ultzmann's  apparatus  in,  57. 
formulae  for  astringent  injections 

in,  .33. 
methodic   treatment   of,   30. 
technique  of  injecting  in,  33. 
the  use  of  injections  in,  34. 
therapeutic    treatment    of,    31. 
treatment  of  the  increasing  stage 
of,  31. 
chronic,  46. 

anterior  and  posterior,  prognosis 

of,  67. 
anterior  and  posterior,  summary 

of  treatment  of,  66. 
method  of  examining  a  case  of, 

68. 
pathological  changes  in,  70. 
predisposing  causes  of,  46. 
gonorrhceal,  22. 
posterior,  41. 
acute,  41. 
chronic,   41,  61. 
diagnosis   of,   62. 
instillations  in,  64. 
irrigation   in,  64. 
passage  of  sounds  in,  65. 
pathology  of,  61. 
symptoms  of,  63. 
treatment  of,  64. 
diagnosis  of,  42. 
subacute,  41. 
sj'mptoms  of,  42. 
treatment   of    the    mild   form   of, 

43. 
treatment  of  the  severe  form  of, 
44. 


Urethrites,  simple,  22. 
treatment  of,  23. 
specific,  22. 
Urethroscopy,  08. 

Urethrotomy,  combined  external  and 
internal,    127. 
external,  Gouley's  operation  with  a 
guide,   121. 
Guiteras's  trocar  in,  124. 
recontraction     of     the     stricture 

after,  126. 
retrograde      catheterization      in, 

124. 
treatment  after,  125. 
Wheelhouse's    operation   without 
a  guide,  123. 
Urinarj'  fever,  130. 
acute,  130. 
chronic,  130. 
etiology  of,  130. 
prognosis  of,  130. 
treatment  of,  131. 
Urine,   extravasation   of,   128. 

treatment  of,  129. 
Uterus  masculinus,  21. 


Varicocele.  265. 
diagnosis  of,  266. 
etiology  of,  205. 
excision  of  a  portion  of  the  veins 

for,  269. 
subcutaneous  ligation  of  the  veins 

for,  269. 
symptoms  of,  266. 
treatment  of,  269. 
Verumontanum,  21. 
Vesiculitis,  atonic,  92,  95. 

chronic,  with  perivesiculitis,  96. 

without  perivesiculitis,  96. 
inflammatory,  92. 
seminal,  acute,  91. 
diagnosis  of,  91. 
symptoms  of,  91. 
treatment  of,  92. 
chronic,  92. 

etiology   of,   96. 
diagnosis  of,  98. 
symptoms   of,   97. 
tuberculous,  90. 
treatment  of,  100. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-40m-5,'67(H2161s8)4939 


